Provider Demographics
NPI:1750040499
Name:GOLDEN STATE MARRIAGE AND FAMILY THERAPY, A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:GOLDEN STATE MARRIAGE AND FAMILY THERAPY, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:BASALONE
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:657-900-8655
Mailing Address - Street 1:250 EL CAMINO REAL STE 213
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3656
Mailing Address - Country:US
Mailing Address - Phone:657-900-8655
Mailing Address - Fax:657-900-8656
Practice Address - Street 1:250 EL CAMINO REAL STE 213
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3656
Practice Address - Country:US
Practice Address - Phone:657-900-8655
Practice Address - Fax:657-900-8656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-09
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1053664649OtherNPI