Provider Demographics
NPI:1194364414
Name:QUILICI, CHANNING
Entity Type:Individual
Prefix:
First Name:CHANNING
Middle Name:
Last Name:QUILICI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHANNING
Other - Middle Name:
Other - Last Name:DAHL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1500 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94109-4523
Mailing Address - Country:US
Mailing Address - Phone:415-474-7310
Mailing Address - Fax:415-474-9934
Practice Address - Street 1:1500 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-4523
Practice Address - Country:US
Practice Address - Phone:415-474-7310
Practice Address - Fax:415-474-9934
Is Sole Proprietor?:No
Enumeration Date:2020-01-03
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101Y00000X
171M00000X, 390200000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program