Provider Demographics
NPI:1447782115
Name:KOLTUN, ASTRID
Entity Type:Individual
Prefix:
First Name:ASTRID
Middle Name:
Last Name:KOLTUN
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 1:12 PENNY LN
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:CA
Mailing Address - Zip Code:94930-1319
Mailing Address - Country:US
Mailing Address - Phone:415-686-8145
Mailing Address - Fax:
Practice Address - Street 1:1330 LINCOLN AVENUE
Practice Address - Street 2:SUITE #201
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:99401
Practice Address - Country:US
Practice Address - Phone:415-459-5999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-31
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9330947390200000X
CA123302106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program