Basic Information
| Provider Information | |||||||||
| NPI: | 1104999051 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WARDLE | ||||||||
| FirstName: | GEORGIANA | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 652 SAUSALITO BLVD | ||||||||
| Address2: | |||||||||
| City: | SAUSALITO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949652331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4153326246 | ||||||||
| FaxNumber: | 4153313949 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 NORTHGATE DR | ||||||||
| Address2: | FAMILY SERVICE AGENCY OF MARIN | ||||||||
| City: | SAN RAFAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949033680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154915700 | ||||||||
| FaxNumber: | 4154915750 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MFT28159 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.