Provider Demographics
NPI:1871504951
Name:KOKE, THERESA (MFT)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:KOKE
Suffix:
Gender:F
Credentials:MFT
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 672
Mailing Address - Street 2:
Mailing Address - City:WOODACRE
Mailing Address - State:CA
Mailing Address - Zip Code:94973-0672
Mailing Address - Country:US
Mailing Address - Phone:415-488-4411
Mailing Address - Fax:415-488-0818
Practice Address - Street 1:710 B ST.
Practice Address - Street 2:SUITE 7-C
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901
Practice Address - Country:US
Practice Address - Phone:707-583-2339
Practice Address - Fax:415-488-0818
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC27900106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist