Basic Information
| Provider Information | |||||||||
| NPI: | 1619014883 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BUCKELEW PROGRAMS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FAMILY SERVICE AGENCY OF MARIN A DIVISION OF BUCKELEW PROGRAMS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 555 NORTHGATE DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SAN RAFAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949033680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154915700 | ||||||||
| FaxNumber: | 4154915750 | ||||||||
| Practice Location | |||||||||
| Address1: | 3000 BRIDGEWAY | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | SAUSALITO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949651489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4153323129 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2007 | ||||||||
| LastUpdateDate: | 12/19/2012 | ||||||||
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| AuthorizedOfficialLastName: | HALLETT | ||||||||
| AuthorizedOfficialFirstName: | MARGARET | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4154915700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.