Basic Information
| Provider Information | |||||||||
| NPI: | 1073860904 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE STONEWALL PROJECT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1035 MARKET ST | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154873000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1035 MARKET ST | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941031600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154873000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2012 | ||||||||
| LastUpdateDate: | 08/09/2012 | ||||||||
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| AuthorizedOfficialLastName: | MCCONNELL | ||||||||
| AuthorizedOfficialFirstName: | LANE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CLINICAL OPPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 4154873049 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THE SAN FRANCISCO AIDS FOUNDATION | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.F.T.I. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 380096AN | CA | Y | Agencies | Community/Behavioral Health |
No ID Information.