Healthcare Provider Details

I. General information

NPI: 1265633572
Provider Name (Legal Business Name): KAMRY ELAYNE SKOGLUND MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 02/27/2020
Certification Date: 02/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 W 8TH ST 700
TRACY CA
95376-4122
US

IV. Provider business mailing address

850 SAFFRON DR
TRACY CA
95377-8669
US

V. Phone/Fax

Practice location:
  • Phone: 510-299-4792
  • Fax:
Mailing address:
  • Phone: 510-299-4792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC39879
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: