Provider Demographics
NPI:1881069086
Name:WALNUT CREEK CBT CLINIC
Entity type:Organization
Organization Name:WALNUT CREEK CBT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JONAH
Authorized Official - Middle Name:
Authorized Official - Last Name:LAKIN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:650-532-3666
Mailing Address - Street 1:1670 S AMPHLETT BLVD
Mailing Address - Street 2:SUITE 225
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-2510
Mailing Address - Country:US
Mailing Address - Phone:650-532-3666
Mailing Address - Fax:
Practice Address - Street 1:1670 S AMPHLETT BLVD
Practice Address - Street 2:SUITE 225
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-2510
Practice Address - Country:US
Practice Address - Phone:650-532-3666
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-14
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26269103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty