Basic Information
| Provider Information | |||||||||
| NPI: | 1407964638 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPERA | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | V. | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PMHCNS, BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2350 W EL CAMINO REAL FL 2 | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN VIEW | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940406203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4156003503 | ||||||||
| FaxNumber: | 4153691383 | ||||||||
| Practice Location | |||||||||
| Address1: | 2300 CALIFORNIA ST STE 202 | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4156003503 | ||||||||
| FaxNumber: | 4153691383 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2006 | ||||||||
| LastUpdateDate: | 06/12/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN95044800 | CA | N | Nursing Service Providers | Registered Nurse | 163WP0808X | PMH586 | CA | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health | 364S00000X | CNS4252 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | 364SP0809X | 0240982 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health, Adult |
ID Information
| ID | Type | State | Issuer | Description | PMH586 | 01 | CA | STATE MEDICAL LICENSE | OTHER | CNS4252 | 01 | CA | STATE MEDICAL LICENSE | OTHER | RN95044800 | 01 | CA | STATE MEDICAL LICENSE | OTHER |