Provider Demographics
NPI:1073074324
Name:CHILD THERAPY INSTITUTE OF MARIN
Entity Type:Organization
Organization Name:CHILD THERAPY INSTITUTE OF MARIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHERIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHUGHART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-456-7724
Mailing Address - Street 1:1480 LINCOLN AVE STE 8
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-2085
Mailing Address - Country:US
Mailing Address - Phone:415-456-7724
Mailing Address - Fax:
Practice Address - Street 1:3195 CALIFORNIA ST STE D
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-2412
Practice Address - Country:US
Practice Address - Phone:925-434-6889
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-28
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health