Healthcare Provider Details

I. General information

NPI: 1720233778
Provider Name (Legal Business Name): KAREN ANN CIESNICKI PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2008
Last Update Date: 11/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

787 MILLER AVE 10 WILLOW ST., SUITE 1
MILL VALLEY CA
94941-2971
US

IV. Provider business mailing address

787 MILLER AVE
MILL VALLEY CA
94941-2971
US

V. Phone/Fax

Practice location:
  • Phone: 415-846-9809
  • Fax:
Mailing address:
  • Phone: 415-381-6509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY12587
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: