Provider Demographics
NPI:1255560777
Name:PRENDERGAST, JOHN JOSEPH (PHD, MFT)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:JOSEPH
Last Name:PRENDERGAST
Suffix:
Gender:M
Credentials:PHD, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 5TH AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-2928
Mailing Address - Country:US
Mailing Address - Phone:415-453-8832
Mailing Address - Fax:
Practice Address - Street 1:900 5TH AVE STE 203
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2928
Practice Address - Country:US
Practice Address - Phone:415-453-8832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-06
Last Update Date:2009-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT20305106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist