Provider Demographics
NPI:1538651872
Name:MITTELSTADT, KAREN MARIE (LAC)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:MARIE
Last Name:MITTELSTADT
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 37TH AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-5518
Mailing Address - Country:US
Mailing Address - Phone:805-698-5886
Mailing Address - Fax:
Practice Address - Street 1:884 PORTOLA RD STE A5
Practice Address - Street 2:
Practice Address - City:PORTOLA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94028-7265
Practice Address - Country:US
Practice Address - Phone:805-698-5886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-02
Last Update Date:2018-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16740171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty