Provider Demographics
NPI:1821378225
Name:POMMERENK, AVA
Entity Type:Individual
Prefix:
First Name:AVA
Middle Name:
Last Name:POMMERENK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 ELM ST STE 212
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-3070
Mailing Address - Country:US
Mailing Address - Phone:650-591-9623
Mailing Address - Fax:650-591-4163
Practice Address - Street 1:200 INDUSTRIAL RD STE 128
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-6296
Practice Address - Country:US
Practice Address - Phone:650-591-3636
Practice Address - Fax:650-591-3600
Is Sole Proprietor?:No
Enumeration Date:2011-08-17
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA94-3094966101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health