Provider Demographics
NPI:1154713774
Name:CHILD THERAPY INSTITUTE OF MARIN
Entity type:Organization
Organization Name:CHILD THERAPY INSTITUTE OF MARIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:N
Authorized Official - Last Name:LUKAS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:415-456-7724
Mailing Address - Street 1:1480 LINCOLN AVE STE 8
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-2085
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:720 SOUTHPOINT BLVD
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-7495
Practice Address - Country:US
Practice Address - Phone:707-237-3644
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-19
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)