1073137295 NPI number — MINDFUL LIVING, A MARRIAGE AND FAMILY THERAPY CORPORATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073137295 NPI number — MINDFUL LIVING, A MARRIAGE AND FAMILY THERAPY CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MINDFUL LIVING, A MARRIAGE AND FAMILY THERAPY CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073137295
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 GREEN ST STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN FRANCISCO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94111-1356
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
415-890-3791
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 GREEN ST STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN FRANCISCO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94111-1356
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
415-890-3791
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/03/2020

Additional Information

Authorized Official

Authorized Official Last Name:
ERTLEY
Authorized Official First Name:
LAURIE PHUONG
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
415-890-3791

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 85042 . This is a "BOARD BEHAVIORAL SERVICES" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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