Provider Demographics
NPI:1134641731
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:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LUKAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-456-7724
Mailing Address - Street 1:1480 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-2084
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11100 SAN PABLO AVE STE 205
Practice Address - Street 2:
Practice Address - City:EL CERRITO
Practice Address - State:CA
Practice Address - Zip Code:94530-2100
Practice Address - Country:US
Practice Address - Phone:510-525-6225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILD THERAPY INSTITUTE OF MARIN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-07-14
Last Update Date:2017-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)