Provider Demographics
NPI:1841209251
Name:KOHLSTROM, STEVEN G (PHD)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:G
Last Name:KOHLSTROM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 GOUGH ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94102-5946
Mailing Address - Country:US
Mailing Address - Phone:415-336-2638
Mailing Address - Fax:
Practice Address - Street 1:211 GOUGH ST
Practice Address - Street 2:SUITE 103
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94102-5946
Practice Address - Country:US
Practice Address - Phone:415-336-2638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2009-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17904103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PSY179040Medicaid
CA00PSY179040Medicaid