Provider Demographics
NPI:1497806293
Name:WIKSTROM, MARIETTA (LMFT)
Entity Type:Individual
Prefix:MS
First Name:MARIETTA
Middle Name:
Last Name:WIKSTROM
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:MS
Other - First Name:MARIETTA
Other - Middle Name:W
Other - Last Name:CHAMPLIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:303 41ST ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94805-2221
Mailing Address - Country:US
Mailing Address - Phone:510-374-7204
Mailing Address - Fax:
Practice Address - Street 1:303 41ST ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94805-2221
Practice Address - Country:US
Practice Address - Phone:510-374-7204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20691106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist