Healthcare Provider Details

I. General information

NPI: 1568967768
Provider Name (Legal Business Name): PAULA F MIERZEJEWSKI LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2018
Last Update Date: 03/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 C ST STE 9
SAN RAFAEL CA
94901-3853
US

IV. Provider business mailing address

361 FORREST AVE
FAIRFAX CA
94930-1814
US

V. Phone/Fax

Practice location:
  • Phone: 415-491-4705
  • Fax:
Mailing address:
  • Phone: 415-453-4037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number105054
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: