Provider Demographics
NPI:1164303111
Name:FRIED, MAX BENJAMIN
Entity type:Individual
Prefix:
First Name:MAX
Middle Name:BENJAMIN
Last Name:FRIED
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 TAMAL VISTA BLVD STE 205
Mailing Address - Street 2:
Mailing Address - City:CORTE MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:94925-1147
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21 TAMAL VISTA BLVD STE 205
Practice Address - Street 2:
Practice Address - City:CORTE MADERA
Practice Address - State:CA
Practice Address - Zip Code:94925-1147
Practice Address - Country:US
Practice Address - Phone:415-236-9633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-08
Last Update Date:2025-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT157788106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist