1629451703 NPI number — BIG DOG COUNSELING, INC.

Table of content: (NPI 1629451703)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629451703 NPI number — BIG DOG COUNSELING, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BIG DOG COUNSELING, INC.
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:
1629451703
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/25/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
815 CREED RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAKLAND
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94610-1826
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-427-7785
Provider Business Mailing Address Fax Number:
510-625-0662

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1683 NOVATO BLVD
Provider Second Line Business Practice Location Address:
SUITE 1B
Provider Business Practice Location Address City Name:
NOVATO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94947-3200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-427-7785
Provider Business Practice Location Address Fax Number:
510-625-0662
Provider Enumeration Date:
07/07/2015

Additional Information

Authorized Official

Authorized Official Last Name:
PARKS
Authorized Official First Name:
LOUISA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
510-427-7785

Provider Taxonomy Codes

  • Taxonomy code: 103G00000X , with the licence number:  PSY24459 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TC0700X , with the licence number: PSY24459 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: PSY24459 . This is a "CA BOARD OF PSYCHOLOGY LICENSE NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: FX694A . This is a "MEDICARE PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 816671 . This is a "MEDICARE UIN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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