MEDICARE: HADI KOESNODIHARDJO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	MFC50900	CA

General Provider Information

NPI Number	:	1073735700
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HADI KOESNODIHARDJO

Provider Business Mailing Address
First Line	:	PO BOX 70
Second Line	:
City	:	REDWOOD CITY
State	:	CA
Zip	:	94064-0070
Country	:	US
Telephone Number	:	415-968-9540
Fax Number	:	650-550-9189

Provider Business Practice Location Address
First Line	:	855 JEFFERSON AVE UNIT 70
Second Line	:
City	:	REDWOOD CITY
State	:	CA
Zip	:	94064-7200
Country	:	US
Telephone Number	:	415-968-9540
Fax Number	:	650-550-9189

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	12/21/2025

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