Basic Information
| Provider Information | |||||||||
| NPI: | 1215388764 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MOMENTUM FOR HEALTH - CRISIS RESIDENTIAL | ||||||||
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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 | ||||||||
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| Practice Location | |||||||||
| Address1: | 101 JOSE FIGUERES AVE STE 10 | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951162022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082617777 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2016 | ||||||||
| LastUpdateDate: | 07/24/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DEWITT | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| 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 | 000008369 | 05 | CA | MEDICAID | ZZZ01125Z | 01 | CA | MEDICARE ID-TYPE UNSPECIFIED | OTHER |