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NPI Code Detail

MEDICARE: MS. MARIETTA WIKSTROM LMFT

MEDICARE: MS. MARIETTA WIKSTROM LMFT
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
1106H00000XMarriage & Family Therapist20691CA

General Provider Information

NPI Number : 1497806293
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. MARIETTA WIKSTROM LMFT
Provider Business Mailing Address
First Line : 303 41ST ST
Second Line :
City : RICHMOND
State : CA
Zip : 94805-2221
Country : US
Telephone Number : 510-374-7204
Fax Number :
Provider Business Practice Location Address
First Line : 303 41ST ST
Second Line :
City : RICHMOND
State : CA
Zip : 94805-2221
Country : US
Telephone Number : 510-374-7204
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/16/2007
Last Update Date : 07/08/2007

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