Provider Demographics
NPI:1568185619
Name:SEA CHANGE PSYCHOTHERAPY INCORPORATED
Entity Type:Organization
Organization Name:SEA CHANGE PSYCHOTHERAPY INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AD CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TARA
Authorized Official - Middle Name:L
Authorized Official - Last Name:KLINE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:415-967-2025
Mailing Address - Street 1:203 FLAMINGO RD #209
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-4149
Mailing Address - Country:US
Mailing Address - Phone:415-987-1187
Mailing Address - Fax:
Practice Address - Street 1:164 DONAHUE ST
Practice Address - Street 2:
Practice Address - City:SAUSALITO
Practice Address - State:CA
Practice Address - Zip Code:94965
Practice Address - Country:US
Practice Address - Phone:415-967-2025
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-23
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health