Healthcare Provider Details

I. General information

NPI: 1346769841
Provider Name (Legal Business Name): ANASTASIA MEDIA GORDEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2017
Last Update Date: 12/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6147 SUTTER AVE
CARMICHAEL CA
95608
US

IV. Provider business mailing address

6147 SUTTER AVE
CARMICHAEL CA
95608-2738
US

V. Phone/Fax

Practice location:
  • Phone: 916-971-7640
  • Fax:
Mailing address:
  • Phone: 916-971-7640
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number89876
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: