Basic Information
| Provider Information | |||||||||
| NPI: | 1386264372 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EMMONS | ||||||||
| FirstName: | MEGAN | ||||||||
| MiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 E COLORADO BLVD STE 560 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911062380 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1922 THE ALAMEDA | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951261457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082546828 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2020 | ||||||||
| LastUpdateDate: | 09/09/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 08/04/2022 | ||||||||
| NPIReactivationDate: | 09/07/2022 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.