Provider Demographics
NPI:1518398528
Name:GERVAIS, ALLISON (MFT)
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:
Last Name:GERVAIS
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3270 KERNER BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-4840
Mailing Address - Country:US
Mailing Address - Phone:415-218-5401
Mailing Address - Fax:
Practice Address - Street 1:3270 KERNER BLVD
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-4840
Practice Address - Country:US
Practice Address - Phone:415-218-5401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-02
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA94579106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist