Basic Information
| Provider Information | |||||||||
| NPI: | 1013489053 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SENECA FAMILY OF AGENCIES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SENECA FIRST STREET GILROY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2275 ARLINGTON DR | ||||||||
| Address2: | |||||||||
| City: | SAN LEANDRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945781132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103171444 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 383 1ST ST | ||||||||
| Address2: | |||||||||
| City: | GILROY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950205028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4085542550 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/31/2018 | ||||||||
| LastUpdateDate: | 10/28/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOBSON | ||||||||
| AuthorizedOfficialFirstName: | SANDY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | QUALITY ASSURANCE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5107255727 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SENECA FAMILY OF AGENCIES | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 0015 | 05 | CA | MEDICAID |