MEDICARE: THE 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1760891931
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE 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	:

Provider Business Practice Location Address
First Line	:	2300 MARTIN LUTHER KING JR WAY
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94704-1412
Country	:	US
Telephone Number	:	510-644-6310
Fax Number	:

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

Provider Enumeration Date	:	08/12/2014
Last Update Date	:	05/20/2025

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