Basic Information
| Provider Information | |||||||||
| NPI: | 1528412608 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BACCARAT | ||||||||
| FirstName: | MAXIMILIAN | ||||||||
| MiddleName: | MALAK | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MFTI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3974 20TH ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941142907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4155741943 | ||||||||
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| Practice Location | |||||||||
| Address1: | 684 ELLIS ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941098090 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154094611 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2016 | ||||||||
| LastUpdateDate: | 04/14/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 92470 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1720385032 | 05 | CA | MEDICAID |