Basic Information
| Provider Information | |||||||||
| NPI: | 1639226814 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TLC CHILD AND FAMILY SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TLC CHILD AND FAMILY SERVICES | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1800 GRAVENSTEIN HWY N | ||||||||
| Address2: | SUITE A | ||||||||
| City: | SEBASTOPOL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954722607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078237300 | ||||||||
| FaxNumber: | 7078233410 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 GRAVENSTEIN HWY N | ||||||||
| Address2: | BLDG A - E | ||||||||
| City: | SEBASTOPOL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954722607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078237300 | ||||||||
| FaxNumber: | 7078233410 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2007 | ||||||||
| LastUpdateDate: | 03/03/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FETTE | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7076349932 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | MFT | ||||||||
| NPICertificationDate: | 03/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
No ID Information.