Provider Demographics
NPI:1003583220
Name:SONG, PHOENIX (LMFT)
Entity Type:Individual
Prefix:
First Name:PHOENIX
Middle Name:
Last Name:SONG
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 SHATTUCK AVE, STE 12
Mailing Address - Street 2:#228
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94709-1411
Mailing Address - Country:US
Mailing Address - Phone:415-545-8215
Mailing Address - Fax:
Practice Address - Street 1:1400 SHATTUCK AVE, STE 12
Practice Address - Street 2:#228
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94709-1411
Practice Address - Country:US
Practice Address - Phone:415-545-8215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-25
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA109093106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist