Provider Demographics
NPI:1720566128
Name:THE LOTUS COLLABORATIVE, INC., A PSYCHOLOGY CLINIC
Entity Type:Organization
Organization Name:THE LOTUS COLLABORATIVE, INC., A PSYCHOLOGY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:831-600-7103
Mailing Address - Street 1:603 MISSION ST
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-3612
Mailing Address - Country:US
Mailing Address - Phone:831-600-7103
Mailing Address - Fax:
Practice Address - Street 1:2500 MARKET ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94114-1915
Practice Address - Country:US
Practice Address - Phone:415-931-3731
Practice Address - Fax:415-931-3739
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE LOTUS COLLABORATIVE, INC., A PSYCHOLOGY CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-07-30
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY24204103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1407120579Medicaid