Provider Demographics
NPI:1275234494
Name:MACKENZIE SODESTROM MARRIAGE & FAMILY THERAPY, INC.
Entity Type:Organization
Organization Name:MACKENZIE SODESTROM MARRIAGE & FAMILY THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MACKENZIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SODESTROM
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:925-640-0795
Mailing Address - Street 1:370 GRAND AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94610-4874
Mailing Address - Country:US
Mailing Address - Phone:510-210-1191
Mailing Address - Fax:
Practice Address - Street 1:370 GRAND AVE STE 4
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94610-4874
Practice Address - Country:US
Practice Address - Phone:510-210-1191
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-14
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty