Provider Demographics
NPI:1497860068
Name:INSTITUTE ON AGING
Entity Type:Organization
Organization Name:INSTITUTE ON AGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT CLINICAL PROGRAMS
Authorized Official - Prefix:DR
Authorized Official - First Name:THERESE
Authorized Official - Middle Name:ANTONIA
Authorized Official - Last Name:TEN TUSSCHER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:415-750-4180
Mailing Address - Street 1:3330 GEARY BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94118-3347
Mailing Address - Country:US
Mailing Address - Phone:415-750-4180
Mailing Address - Fax:415-750-4108
Practice Address - Street 1:3330 GEARY BLVD
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94118-3347
Practice Address - Country:US
Practice Address - Phone:415-750-4180
Practice Address - Fax:415-750-4108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15889103G00000X
CAPSY20118103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ187572Medicare ID - Type Unspecified