Basic Information
| Provider Information | |||||||||
| NPI: | 1417675653 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WANG | ||||||||
| FirstName: | ERICA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2001 THE ALAMEDA | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951261136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082617777 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2001 THE ALAMEDA | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951261136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082617777 | ||||||||
| FaxNumber: | 4082592273 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2022 | ||||||||
| LastUpdateDate: | 09/16/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 251S00000X | N | Agencies | Community/Behavioral Health | 261QC1500X | N | Ambulatory Health Care Facilities | Clinic/Center | Community Health | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QM0855X | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QR0405X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.