Provider Demographics
NPI:1366740839
Name:LIVING WELL ASSISTED LIVING AT HOME
Entity type:Organization
Organization Name:LIVING WELL ASSISTED LIVING AT HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:THERESE
Authorized Official - Middle Name:ANTONIA
Authorized Official - Last Name:TEN TUSSCHER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:415-515-7618
Mailing Address - Street 1:202 DONAHUE ST
Mailing Address - Street 2:
Mailing Address - City:SAUSALITO
Mailing Address - State:CA
Mailing Address - Zip Code:94965-1029
Mailing Address - Country:US
Mailing Address - Phone:800-805-7104
Mailing Address - Fax:
Practice Address - Street 1:202 DONAHUE ST
Practice Address - Street 2:
Practice Address - City:SAUSALITO
Practice Address - State:CA
Practice Address - Zip Code:94965-1029
Practice Address - Country:US
Practice Address - Phone:800-805-7104
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-08
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 15799103T00000X
163WC2100X, 163WG0600X, 163WH0200X, 372500000X, 372600000X, 3747A0650X, 3747P1801X, 374U00000X, 376J00000X, 376K00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253Z00000XAgenciesIn Home Supportive CareGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No163WC2100XNursing Service ProvidersRegistered NurseContinence CareGroup - Multi-Specialty
No163WG0600XNursing Service ProvidersRegistered NurseGerontologyGroup - Multi-Specialty
No163WH0200XNursing Service ProvidersRegistered NurseHome HealthGroup - Multi-Specialty
No372500000XNursing Service Related ProvidersChore ProviderGroup - Multi-Specialty
No372600000XNursing Service Related ProvidersAdult CompanionGroup - Multi-Specialty
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Multi-Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty
No376J00000XNursing Service Related ProvidersHomemakerGroup - Multi-Specialty
No376K00000XNursing Service Related ProvidersNurse's AideGroup - Multi-Specialty