Provider Demographics
NPI:1093190407
Name:MID-PENINSULA EATING DISORDER CLINIC, A MARRIAGE AND FAMILY THERAPY CO
Entity Type:Organization
Organization Name:MID-PENINSULA EATING DISORDER CLINIC, A MARRIAGE AND FAMILY THERAPY CO
Other - Org Name:MPEDC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:WENDI
Authorized Official - Middle Name:JO
Authorized Official - Last Name:CONLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:424-298-8901
Mailing Address - Street 1:220 CALIFORNIA AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94306-1627
Mailing Address - Country:US
Mailing Address - Phone:650-319-7225
Mailing Address - Fax:650-618-5556
Practice Address - Street 1:220 CALIFORNIA AVE STE 100
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94306-1627
Practice Address - Country:US
Practice Address - Phone:650-319-7225
Practice Address - Fax:650-618-5556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-27
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT44947106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty