Basic Information
| Provider Information | |||||||||
| NPI: | 1487673596 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BEAVER | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 275 HOSPITAL PKWY | ||||||||
| Address2: | SUITE 470 | ||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951191106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4089723364 | ||||||||
| FaxNumber: | 4089726088 | ||||||||
| Practice Location | |||||||||
| Address1: | 275 HOSPITAL PKWY | ||||||||
| Address2: | SUITE 470 | ||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951191106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4089723364 | ||||||||
| FaxNumber: | 4089726088 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TH0100X | 20328 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Health Service | 103TH0100X | 1565 | CO | N | Behavioral Health & Social Service Providers | Psychologist | Health Service |
ID Information
| ID | Type | State | Issuer | Description | 07015654 | 05 | CA | MEDICAID |