Provider Demographics
NPI:1396324778
Name:MACKINTOSH, LOUISA
Entity type:Individual
Prefix:
First Name:LOUISA
Middle Name:
Last Name:MACKINTOSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6250 ORCHARD STATION RD
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-6226
Mailing Address - Country:US
Mailing Address - Phone:510-866-3001
Mailing Address - Fax:
Practice Address - Street 1:201 ALAMEDA DEL PRADO STE 201
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94949-6698
Practice Address - Country:US
Practice Address - Phone:415-585-5612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-05
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA125265101YM0800X
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health