1477995322 NPI number — THE MINDFUL CENTER FOR INDIVIDUAL COUPLE AND FAMILY THERAPY

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 1477995322 NPI number — THE MINDFUL CENTER FOR INDIVIDUAL COUPLE AND FAMILY THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE MINDFUL CENTER FOR INDIVIDUAL COUPLE AND FAMILY THERAPY
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:
1477995322
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/20/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4797 TELEGRAPH AVE
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
OAKLAND
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94609-2007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-698-2467
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4797 TELEGRAPH AVE
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
OAKLAND
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94609-2007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-698-2467
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/20/2013

Additional Information

Authorized Official

Authorized Official Last Name:
YI
Authorized Official First Name:
KELLY
Authorized Official Middle Name:
S
Authorized Official Title or Position:
DIRECTOR/PSYCHOLOGIST
Authorized Official Telephone Number:
510-698-2467

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  PSY 24210 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1831324524 . This is a "PERSONAL NPI #" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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