Provider Demographics
NPI:1386740652
Name:GUMP, NANCY ILENE (MFT)
Entity type:Individual
Prefix:MS
First Name:NANCY
Middle Name:ILENE
Last Name:GUMP
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 SAN ANSELMO AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:SAN ANSELMO
Mailing Address - State:CA
Mailing Address - Zip Code:94960-2664
Mailing Address - Country:US
Mailing Address - Phone:415-453-5333
Mailing Address - Fax:415-454-6816
Practice Address - Street 1:407 SAN ANSELMO AVE
Practice Address - Street 2:SUITE 6
Practice Address - City:SAN ANSELMO
Practice Address - State:CA
Practice Address - Zip Code:94960-2664
Practice Address - Country:US
Practice Address - Phone:415-453-5333
Practice Address - Fax:415-454-6816
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC25530106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist