Provider Demographics
NPI:1013240647
Name:MICKELSON, TAMARA MARIE
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:MARIE
Last Name:MICKELSON
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 1:701 SHELTER CREEK LN APT 8131
Mailing Address - Street 2:
Mailing Address - City:SAN BRUNO
Mailing Address - State:CA
Mailing Address - Zip Code:94066-3855
Mailing Address - Country:US
Mailing Address - Phone:805-705-9808
Mailing Address - Fax:
Practice Address - Street 1:1885 LUNDY AVE STE 223
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95131-1888
Practice Address - Country:US
Practice Address - Phone:408-284-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-15
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist