Basic Information
| Provider Information | |||||||||
| NPI: | 1174891113 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MOMENTUM FOR HEALTH-DOWNTOWN | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MOMENTUM FOR MENTAL HEALTH | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1922 THE ALAMEDA | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951261457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4086426053 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 540 N 1ST ST | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951125319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4085103420 | ||||||||
| FaxNumber: | 4085103421 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2011 | ||||||||
| LastUpdateDate: | 07/24/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DEWILL | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO, COO | ||||||||
| AuthorizedOfficialTelephone: | 4086426053 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | ZZZ01125Z | 01 | CA | MEDICARE ID-TYPE UNSPECIFIED | OTHER | 000008369 | 05 | CA | MEDICAID |