Provider Demographics
NPI:1245710078
Name:TILDEN, GREGORY MICHAEL (LMFT)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:MICHAEL
Last Name:TILDEN
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 PETALUMA AVE
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-4216
Mailing Address - Country:US
Mailing Address - Phone:203-843-1680
Mailing Address - Fax:
Practice Address - Street 1:11100 SAN PABLO AVE STE 205
Practice Address - Street 2:
Practice Address - City:EL CERRITO
Practice Address - State:CA
Practice Address - Zip Code:94530-2100
Practice Address - Country:US
Practice Address - Phone:510-859-4889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAPCC5424101YM0800X
CA125005106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health