Provider Demographics
NPI:1528412608
Name:BACCARAT, MAXIMILIAN MALAK (MFTI)
Entity Type:Individual
Prefix:MR
First Name:MAXIMILIAN
Middle Name:MALAK
Last Name:BACCARAT
Suffix:
Gender:M
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3974 20TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94114-2907
Mailing Address - Country:US
Mailing Address - Phone:415-574-1943
Mailing Address - Fax:
Practice Address - Street 1:684 ELLIS ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-8090
Practice Address - Country:US
Practice Address - Phone:415-409-4611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-14
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA92470106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1720385032Medicaid