Provider Demographics
NPI:1891728267
Name:WEST COAST POSTTRAUMA RETREAT
Entity Type:Organization
Organization Name:WEST COAST POSTTRAUMA RETREAT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:FAY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:415-720-6653
Mailing Address - Street 1:4460 - 16 REDWOOD HWY
Mailing Address - Street 2:SUITE 362
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-1953
Mailing Address - Country:US
Mailing Address - Phone:415-721-9789
Mailing Address - Fax:
Practice Address - Street 1:4460 - 16 REDWOOD HWY
Practice Address - Street 2:SUITE 362
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-1953
Practice Address - Country:US
Practice Address - Phone:415-721-9789
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 18339323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility