Basic Information
| Provider Information | |||||||||
| NPI: | 1669673158 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIKKELSEN | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | FLORA | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2577 SAN PABLO AVE | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946121159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5104467107 | ||||||||
| FaxNumber: | 5108320609 | ||||||||
| Practice Location | |||||||||
| Address1: | 2577 SAN PABLO AVE | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946121159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5104467107 | ||||||||
| FaxNumber: | 5108320609 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFC33472 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 8132 | 01 | CA | MH PSP | OTHER | 60081 | 01 | CA | ALCOHOL AND DRUG PSP | OTHER |