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General NPI Number Information
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NPI Number | 1124687363
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Entity Type | Organization
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Legal Business Name | MAKENA THERAPY
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Dates
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Enumeration Date | 06/11/2019
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Last Update Date | 01/13/2021
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Provider Practice Location Address
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Address Line | 1660 W LINNE RD STE 223
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City | TRACY
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State | CA
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Zip | 95377-8004
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Country | US
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Telephone | 209-346-7411
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Fax |
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Provider Business Mailing Address
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Address Line | 2455 NAGLEE RD STE 138
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City | TRACY
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State | CA
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Zip | 95304-7324
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Country | US
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Telephone | 209-346-7411
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | SARAH ROSE
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Credential | LMFT
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Telephone | 209-346-7411
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251T00000X
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Taxonomy Name | PACE Provider Organization
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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