Provider Demographics
NPI:1578639316
Name:KOSTRIKEN, DOROTHY L (MA, LMFT)
Entity Type:Individual
Prefix:MS
First Name:DOROTHY
Middle Name:L
Last Name:KOSTRIKEN
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 224
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:95524-0224
Mailing Address - Country:US
Mailing Address - Phone:707-822-5767
Mailing Address - Fax:707-822-5767
Practice Address - Street 1:2934 H ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-4408
Practice Address - Country:US
Practice Address - Phone:707-498-7002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9346106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0224726OtherBLUE CROSS
CA922804Medicaid