Provider Demographics
NPI:1104400555
Name:TEWOLDE, SOSAN
Entity Type:Individual
Prefix:
First Name:SOSAN
Middle Name:
Last Name:TEWOLDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 CONCORD AVE STE 450
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-4959
Mailing Address - Country:US
Mailing Address - Phone:925-933-2627
Mailing Address - Fax:
Practice Address - Street 1:1200 CONCORD AVE STE 450
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-4959
Practice Address - Country:US
Practice Address - Phone:925-933-2627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-11
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health