Basic Information
| Provider Information | |||||||||
| NPI: | 1548708712 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STANFORD | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | LOUISE | ||||||||
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| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HART | ||||||||
| OtherFirstName: | TINA | ||||||||
| OtherMiddleName: | LOUISE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2752 SARGENT AVE | ||||||||
| Address2: | |||||||||
| City: | SAN PABLO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 948061568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5108602474 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1109 SIR FRANCIS DRAKE BLVD | ||||||||
| Address2: | |||||||||
| City: | KENTFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949041418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4152569995 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2017 | ||||||||
| LastUpdateDate: | 02/07/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N9903495 | CA | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.