Provider Demographics
NPI:1861593543
Name:FACCHINO, LOUIS JOSEPH JR (MDIV LMFT)
Entity type:Individual
Prefix:MR
First Name:LOUIS
Middle Name:JOSEPH
Last Name:FACCHINO
Suffix:JR
Gender:M
Credentials:MDIV LMFT
Other - Prefix:MR
Other - First Name:LOUIS
Other - Middle Name:
Other - Last Name:FACCHINO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MDIV LMFT
Mailing Address - Street 1:PO BOX 790
Mailing Address - Street 2:
Mailing Address - City:MILLBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94030-0790
Mailing Address - Country:US
Mailing Address - Phone:650-347-6833
Mailing Address - Fax:650-866-4172
Practice Address - Street 1:39 N SAN MATEO DR
Practice Address - Street 2:SUITE 5
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401
Practice Address - Country:US
Practice Address - Phone:650-347-6833
Practice Address - Fax:650-866-4172
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC6624106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist