Provider Demographics
NPI:1356862809
Name:PEZANOSKI, JOAN A (MFT)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:A
Last Name:PEZANOSKI
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 VALLE VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94610-1921
Mailing Address - Country:US
Mailing Address - Phone:510-414-8240
Mailing Address - Fax:
Practice Address - Street 1:4168 PIEDMONT AVE STE D
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5172
Practice Address - Country:US
Practice Address - Phone:510-625-9850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-05
Last Update Date:2017-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT28023106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist