Provider Demographics
NPI:1497422190
Name:AVRAHAM, EDNA (MFT)
Entity Type:Individual
Prefix:
First Name:EDNA
Middle Name:
Last Name:AVRAHAM
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 1:347 CASTILIAN WAY
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-2325
Mailing Address - Country:US
Mailing Address - Phone:650-773-2460
Mailing Address - Fax:
Practice Address - Street 1:205 E 3RD AVE STE 308
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-4052
Practice Address - Country:US
Practice Address - Phone:650-579-7153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMA20840103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy