Provider Demographics
NPI:1043662380
Name:ROODHUYZEN, MIA ELANA
Entity type:Individual
Prefix:MS
First Name:MIA
Middle Name:ELANA
Last Name:ROODHUYZEN
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 1:806 VENDOLA DR
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-2941
Mailing Address - Country:US
Mailing Address - Phone:415-686-1130
Mailing Address - Fax:
Practice Address - Street 1:806 VENDOLA DR
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-2941
Practice Address - Country:US
Practice Address - Phone:415-686-1130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-11
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA121366106H00000X, 106H00000X
CAIMF93099106H00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist