Basic Information
| Provider Information | |||||||||
| NPI: | 1790009439 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GERVACIO | ||||||||
| FirstName: | CYRYL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 5TH AVE STREET 150 | ||||||||
| Address2: | |||||||||
| City: | SAN RAFAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949012928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154576964 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 900 5TH AVE STREET 150 | ||||||||
| Address2: | |||||||||
| City: | SAN RAFAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949012928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154576964 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2010 | ||||||||
| LastUpdateDate: | 04/16/2010 | ||||||||
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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 | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.