Provider Demographics
NPI:1609228840
Name:SQUARE PEG FOUNDATION
Entity Type:Organization
Organization Name:SQUARE PEG FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOELL
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:DUNLAP
Authorized Official - Suffix:
Authorized Official - Credentials:RBT
Authorized Official - Phone:650-440-5064
Mailing Address - Street 1:80 CABRILLO HWY N STE Q
Mailing Address - Street 2:PMB 402
Mailing Address - City:HALF MOON BAY
Mailing Address - State:CA
Mailing Address - Zip Code:94019-1698
Mailing Address - Country:US
Mailing Address - Phone:650-440-5064
Mailing Address - Fax:
Practice Address - Street 1:12150 SAN MATEO RD
Practice Address - Street 2:
Practice Address - City:HALF MOON BAY
Practice Address - State:CA
Practice Address - Zip Code:94019-7108
Practice Address - Country:US
Practice Address - Phone:650-440-5064
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABCBA 1-14-15647103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty