Basic Information
| Provider Information | |||||||||
| NPI: | 1275176265 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MOMENTUM FOR HEALTH IFSP-ADULT / IFSP-TAY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MOMENTUM FOR MENTAL HEALTH | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
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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: | 2115 THE ALAMEDA | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951261141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4086426053 | ||||||||
| FaxNumber: | 4086426076 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2019 | ||||||||
| LastUpdateDate: | 07/24/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DEWITT | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4086426053 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | ZZZ01125Z | 01 | MEDICARE | OTHER | 0000043EC | 05 | CA | MEDICAID |