Active NPI
Kim Stafford Fahlen, LMFT
- Mental Health Counselor
- San Rafael, CA
National Provider Identifier
1720794712
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Mental Health Counselor
- License
- 41746
- Practice address
- 875 4TH St Ste 6
San Rafael, CA 94901-3242 - Phone
- (415) 578-2978
- NPI assigned
- Jan 24, 2023
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Mental Health Counselor | 101YM0800X | 41746 | CA | Primary |
Addresses
Primary practice location
875 4TH St Ste 6
San Rafael, CA 94901-3242
Mailing address
23 Hacienda CT
San Rafael, CA 94901-1314
Phone (415) 205-4034
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Opted out of Medicare
- Yes, effective Jan 1, 2024 through Jan 1, 2028
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 41746 | CA | MD | Mental Health Counselor |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1674518400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1674518400000",
"number": "1720794712",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "23 HACIENDA CT",
"city": "SAN RAFAEL",
"state": "CA",
"postal_code": "949011314",
"telephone_number": "415-205-4034"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "875 4TH ST STE 6",
"city": "SAN RAFAEL",
"state": "CA",
"postal_code": "949013242",
"telephone_number": "415-578-2978"
}
],
"practiceLocations": [],
"basic": {
"last_name": "FAHLEN",
"first_name": "KIM",
"middle_name": "STAFFORD",
"credential": "LMFT",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2023-01-24",
"last_updated": "2023-01-24",
"certification_date": "2023-01-24",
"status": "A"
},
"taxonomies": [
{
"code": "101YM0800X",
"taxonomy_group": "",
"desc": "Counselor, Mental Health",
"state": "CA",
"license": "41746",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in San Rafael, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 24, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.