Provider Demographics
NPI:1962220483
Name:PROVDA, ALEXANDER SULLIVAN (LMFT)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:SULLIVAN
Last Name:PROVDA
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5377 LOCKSLEY AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94618-1122
Mailing Address - Country:US
Mailing Address - Phone:510-304-3328
Mailing Address - Fax:510-654-4792
Practice Address - Street 1:5377 LOCKSLEY AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94618-1122
Practice Address - Country:US
Practice Address - Phone:510-304-3328
Practice Address - Fax:510-654-4792
Is Sole Proprietor?:No
Enumeration Date:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA148702101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health