Provider Demographics
NPI:1588935076
Name:OLCOTT, KENNETH GENE (MFT)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:GENE
Last Name:OLCOTT
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1703 5TH AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-1826
Mailing Address - Country:US
Mailing Address - Phone:415-419-3590
Mailing Address - Fax:
Practice Address - Street 1:1703 5TH AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-1826
Practice Address - Country:US
Practice Address - Phone:415-419-3590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-16
Last Update Date:2012-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC39008106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist