Provider Demographics
NPI:1073735700
Name:KOESNODIHARDJO, HADI
Entity Type:Individual
Prefix:
First Name:HADI
Middle Name:
Last Name:KOESNODIHARDJO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 70
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94064-0070
Mailing Address - Country:US
Mailing Address - Phone:415-968-9540
Mailing Address - Fax:650-550-9189
Practice Address - Street 1:1161 CHERRY ST
Practice Address - Street 2:SUITE K
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-3135
Practice Address - Country:US
Practice Address - Phone:415-968-9540
Practice Address - Fax:650-550-9189
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC50900106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist