Provider Demographics
NPI:1952684763
Name:EAST BAY FAMILY THERAPY
Entity Type:Organization
Organization Name:EAST BAY FAMILY THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:D
Authorized Official - Last Name:KOMORI STAGER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:925-325-5022
Mailing Address - Street 1:1600 S MAIN ST
Mailing Address - Street 2:SUITE 225
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-5340
Mailing Address - Country:US
Mailing Address - Phone:925-325-5022
Mailing Address - Fax:
Practice Address - Street 1:1600 S MAIN ST
Practice Address - Street 2:SUITE 225
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-5340
Practice Address - Country:US
Practice Address - Phone:925-325-5022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY21734103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty