Basic Information
| Provider Information | |||||||||
| NPI: | 1285877308 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MOMENTUM FOR HEALTH - FSP IMD | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | MOMENTUM FOR MENTAL HEALTH - FSP IMD | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2001 THE ALAMEDA | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951261136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082617777 | ||||||||
| FaxNumber: | 4082486520 | ||||||||
| Practice Location | |||||||||
| Address1: | 86 S 14TH ST | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951122015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4089388500 | ||||||||
| FaxNumber: | 4082954231 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2009 | ||||||||
| LastUpdateDate: | 04/05/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DEWITT | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4086426053 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.