Basic Information
| Provider Information | |||||||||
| NPI: | 1376713412 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY SERVICE AGENCY OF MARIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3270 KERNER BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN RAFAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949014840 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3270 KERNER BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN RAFAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949014840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154915700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2008 | ||||||||
| LastUpdateDate: | 03/05/2008 | ||||||||
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| AuthorizedOfficialLastName: | HALLETT | ||||||||
| AuthorizedOfficialFirstName: | MARGARET | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4154915700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MISS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.