Provider Demographics
NPI:1124687363
Name:MAKENA THERAPY
Entity type:Organization
Organization Name:MAKENA THERAPY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:209-346-7411
Mailing Address - Street 1:2455 NAGLEE RD STE 138
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95304-7324
Mailing Address - Country:US
Mailing Address - Phone:209-346-7411
Mailing Address - Fax:
Practice Address - Street 1:1660 W LINNE RD STE 223
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95377-8004
Practice Address - Country:US
Practice Address - Phone:209-346-7411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-11
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization