Provider Demographics
NPI:1467814525
Name:GENGO, STEVAN (MFT)
Entity Type:Individual
Prefix:DR
First Name:STEVAN
Middle Name:
Last Name:GENGO
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:870 MARKET ST STE 1245
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94102-2926
Mailing Address - Country:US
Mailing Address - Phone:415-710-4415
Mailing Address - Fax:
Practice Address - Street 1:870 MARKET ST STE 1245
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94102-2926
Practice Address - Country:US
Practice Address - Phone:415-710-4415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-27
Last Update Date:2016-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT23621106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist