Provider Demographics
NPI:1679792170
Name:INSDORF, MAGDALENE Y
Entity Type:Individual
Prefix:
First Name:MAGDALENE
Middle Name:Y
Last Name:INSDORF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MAGDALENE
Other - Middle Name:Y
Other - Last Name:WONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 24TH ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94804-1804
Mailing Address - Country:US
Mailing Address - Phone:510-926-5241
Mailing Address - Fax:
Practice Address - Street 1:1806 MARTIN LUTHER KING JR WAY STE 4
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94709-2227
Practice Address - Country:US
Practice Address - Phone:510-467-7456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT 47349106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist