Provider Demographics
NPI:1790216489
Name:CHILD THERAPY INSTITUTE OF MARIN
Entity Type:Organization
Organization Name:CHILD THERAPY INSTITUTE OF MARIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LUKAS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:415-456-7724
Mailing Address - Street 1:1480 LINCOLN AVE
Mailing Address - Street 2:#8
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-2084
Mailing Address - Country:US
Mailing Address - Phone:415-456-7724
Mailing Address - Fax:415-456-1050
Practice Address - Street 1:240 TAMAL VISTA BLVD
Practice Address - Street 2:#155
Practice Address - City:CORTE MADERA
Practice Address - State:CA
Practice Address - Zip Code:94925-1132
Practice Address - Country:US
Practice Address - Phone:415-456-7724
Practice Address - Fax:415-456-1050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-23
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health