MEDICARE: CHILD THERAPY INSTITUTE OF MARIN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1447531306
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHILD THERAPY INSTITUTE OF MARIN

Provider Business Mailing Address
First Line	:	1480 LINCOLN AVE STE 8
Second Line	:
City	:	SAN RAFAEL
State	:	CA
Zip	:	94901-2085
Country	:	US
Telephone Number	:	415-456-7724
Fax Number	:	415-456-1050

Provider Business Practice Location Address
First Line	:	11100 SAN PABLO AVE.
Second Line	:	205 & 208
City	:	EL CERRITO
State	:	CA
Zip	:	94530-2100
Country	:	US
Telephone Number	:	510-525-6225
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	DR. BRIAN LUKAS
Credential	:	PH.D.
Telephone Number	:	415-456-7724

Provider Enumeration Date	:	09/06/2011
Last Update Date	:	07/06/2023

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