MEDICARE: PRISM PSYCHOTHERAPY LLC

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	:	1881419422
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRISM PSYCHOTHERAPY LLC

Provider Business Mailing Address
First Line	:	250 WHITMORE ST APT 308
Second Line	:
City	:	OAKLAND
State	:	CA
Zip	:	94611-4631
Country	:	US
Telephone Number	:	415-312-1912
Fax Number	:

Provider Business Practice Location Address
First Line	:	250 WHITMORE ST APT 308
Second Line	:
City	:	OAKLAND
State	:	CA
Zip	:	94611-4631
Country	:	US
Telephone Number	:	415-312-1912
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. KALANI PERREIRA
Credential	:	LMFT, 103605
Telephone Number	:	415-312-1912

Provider Enumeration Date	:	11/19/2024
Last Update Date	:	11/19/2024

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Directions to “PRISM PSYCHOTHERAPY LLC ” Practice Location

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