MEDICARE: SANKOFA COMMUNITY COUNSELING, INC

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	251B00000X	Case Management Agency	MFC 49566, LPC 247	CA
2	251S00000X	Community/Behavioral Health Agency	MFC 49566, LPC 247	CA

General Provider Information

NPI Number	:	1952728933
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SANKOFA COMMUNITY COUNSELING, INC

Provider Business Mailing Address
First Line	:	PO BOX 3082
Second Line	:
City	:	REDWOOD CITY
State	:	CA
Zip	:	94064-3082
Country	:	US
Telephone Number	:	650-454-6109
Fax Number	:

Provider Business Practice Location Address
First Line	:	3705 HAVEN AVE
Second Line	:	STE 115
City	:	MENLO PARK
State	:	CA
Zip	:	94025-1011
Country	:	US
Telephone Number	:	650-454-6109
Fax Number	:	650-231-2633

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MS. LA TANYA ALICIA TAKLA
Credential	:	LMFT, LPCC
Telephone Number	:	650-454-6109

Provider Enumeration Date	:	03/27/2014
Last Update Date	:	07/30/2015

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