Provider Demographics
NPI:1053795831
Name:PODKOMORSKI, MATT
Entity type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:PODKOMORSKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2719 ENCINAL AVE STE A4
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-4784
Mailing Address - Country:US
Mailing Address - Phone:510-764-3250
Mailing Address - Fax:
Practice Address - Street 1:2719 ENCINAL AVE STE A4
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501
Practice Address - Country:US
Practice Address - Phone:510-764-3250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-12
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA84360106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist