Basic Information
| Provider Information | |||||||||
| NPI: | 1134333180 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CITY OF SAN JOSE GRACE COMMUNITY CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 484 E SAN FERNANDO ST | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951123513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082930422 | ||||||||
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| Practice Location | |||||||||
| Address1: | 484 E SAN FERNANDO ST | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951123513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082930422 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BLEVINS | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4082930422 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PH. D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | PSY 14707 | CA | Y | Agencies | Community/Behavioral Health |
No ID Information.