Provider Demographics
NPI:1669703542
Name:THURSTON, TOM (MFT)
Entity type:Individual
Prefix:MR
First Name:TOM
Middle Name:
Last Name:THURSTON
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 D ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-3707
Mailing Address - Country:US
Mailing Address - Phone:415-419-3525
Mailing Address - Fax:
Practice Address - Street 1:711 D ST
Practice Address - Street 2:SUITE 201
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-3707
Practice Address - Country:US
Practice Address - Phone:415-419-3525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-17
Last Update Date:2010-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC46718106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist