Provider Demographics
NPI:1699091769
Name:MOMTCHILOFF, ALEXANDER JOHN (MA)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:JOHN
Last Name:MOMTCHILOFF
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:383 RHODE ISLAND ST # 201
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94103-5177
Mailing Address - Country:US
Mailing Address - Phone:510-545-6384
Mailing Address - Fax:
Practice Address - Street 1:383 RHODE ISLAND ST # 201
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94103-5177
Practice Address - Country:US
Practice Address - Phone:510-545-6384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-14
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC51908106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist