Provider Demographics
NPI:1356749279
Name:MASONIC CENTER FOR YOUTH AND FAMILIES
Entity type:Organization
Organization Name:MASONIC CENTER FOR YOUTH AND FAMILIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:BONETTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-929-3001
Mailing Address - Street 1:6 FUNSTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94129-1109
Mailing Address - Country:US
Mailing Address - Phone:415-929-3001
Mailing Address - Fax:
Practice Address - Street 1:6 FUNSTON AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94129
Practice Address - Country:US
Practice Address - Phone:415-929-3001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MASONIC HOMES OF CALIFORNIA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-12-09
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550001484261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health