Provider Demographics
NPI:1215496799
Name:NEWTON, MAKENNA (PHD)
Entity type:Individual
Prefix:
First Name:MAKENNA
Middle Name:
Last Name:NEWTON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 41ST ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94805-2221
Mailing Address - Country:US
Mailing Address - Phone:510-374-7201
Mailing Address - Fax:
Practice Address - Street 1:13585 SAN PABLO AVE.
Practice Address - Street 2:1ST FLOOR
Practice Address - City:SAN PABLO
Practice Address - State:CA
Practice Address - Zip Code:94806
Practice Address - Country:US
Practice Address - Phone:510-942-4619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-14
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA33269103TC2200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent