Provider Demographics
NPI:1174080139
Name:ZYDOW, MILAN DOUGLAS
Entity type:Individual
Prefix:
First Name:MILAN
Middle Name:DOUGLAS
Last Name:ZYDOW
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 1:376 COLUSA AVE
Mailing Address - Street 2:
Mailing Address - City:KENSINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:94707-1213
Mailing Address - Country:US
Mailing Address - Phone:510-816-6258
Mailing Address - Fax:
Practice Address - Street 1:376 COLUSA AVE
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:CA
Practice Address - Zip Code:94707-1213
Practice Address - Country:US
Practice Address - Phone:510-816-6258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-26
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40579101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty