Provider Demographics
NPI:1326633702
Name:MARIN YOUTH THERAPY INC.
Entity Type:Organization
Organization Name:MARIN YOUTH THERAPY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KIERSTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KOTAKA
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:707-834-4078
Mailing Address - Street 1:PO BOX 193
Mailing Address - Street 2:
Mailing Address - City:SAN GERONIMO
Mailing Address - State:CA
Mailing Address - Zip Code:94963-0193
Mailing Address - Country:US
Mailing Address - Phone:707-834-4078
Mailing Address - Fax:
Practice Address - Street 1:101 MEADOW WAY
Practice Address - Street 2:
Practice Address - City:SAN GERONIMO
Practice Address - State:CA
Practice Address - Zip Code:94963
Practice Address - Country:US
Practice Address - Phone:707-834-4078
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-08
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty