Basic Information
| Provider Information | |||||||||
| NPI: | 1336596303 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GUNDERSON HIGH SCHOOL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 160 E VIRGINIA ST STE 280 | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951125817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082876200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 622 GAUNDABERT LN | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951362830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082876200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2016 | ||||||||
| LastUpdateDate: | 05/19/2016 | ||||||||
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| AuthorizedOfficialLastName: | GISSIBLE | ||||||||
| AuthorizedOfficialFirstName: | LOREN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROGRAM COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 4082876200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GARDNER FAMILY CARE CORPORATION | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.