Provider Demographics
NPI:1073137295
Name:MINDFUL LIVING, A MARRIAGE AND FAMILY THERAPY CORPORATION
Entity Type:Organization
Organization Name:MINDFUL LIVING, A MARRIAGE AND FAMILY THERAPY CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE PHUONG
Authorized Official - Middle Name:
Authorized Official - Last Name:ERTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:415-890-3791
Mailing Address - Street 1:200 GREEN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94111-1356
Mailing Address - Country:US
Mailing Address - Phone:415-890-3791
Mailing Address - Fax:
Practice Address - Street 1:200 GREEN ST STE 200
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94111-1356
Practice Address - Country:US
Practice Address - Phone:415-890-3791
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-03
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA85042OtherBOARD BEHAVIORAL SERVICES