Provider Demographics
NPI:1598156796
Name:CASA SERENA EATING DISORDERS PROGRAM SAN FRANCISCO
Entity Type:Organization
Organization Name:CASA SERENA EATING DISORDERS PROGRAM SAN FRANCISCO
Other - Org Name:JACQUELYN L HOLMES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:JACQUELYN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:MFT
Authorized Official - Phone:415-757-0402
Mailing Address - Street 1:3150 CALIFORNIA ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115-2464
Mailing Address - Country:US
Mailing Address - Phone:415-757-0402
Mailing Address - Fax:415-440-4402
Practice Address - Street 1:1868 CLAYTON RD
Practice Address - Street 2:SUTIE 123
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-2547
Practice Address - Country:US
Practice Address - Phone:925-682-8252
Practice Address - Fax:925-682-8313
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CASA SERENA EATING DISORDERS PROGRAM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-02-10
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC25575106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty