Provider Demographics
NPI:1225765787
Name:AN INDIVIDUAL MARRIAGE AND RELATIONSHIP THERAPY CORPORATION
Entity type:Organization
Organization Name:AN INDIVIDUAL MARRIAGE AND RELATIONSHIP THERAPY CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:PERI
Authorized Official - Last Name:SUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:650-762-5284
Mailing Address - Street 1:1015 SHORELINE DR
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94404-2047
Mailing Address - Country:US
Mailing Address - Phone:410-459-5024
Mailing Address - Fax:
Practice Address - Street 1:1015 SHORELINE DR
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94404-2047
Practice Address - Country:US
Practice Address - Phone:650-762-5284
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-04
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)