Basic Information
Provider Information | |||||||||
NPI: | 1497491278 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MOMENTUM FOR HEALTH - TRUST | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1922 THE ALAMEDA | ||||||||
Address2: |   | ||||||||
City: | SAN JOSE | ||||||||
State: | CA | ||||||||
PostalCode: | 951261457 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4086426053 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4139 EL CAMINO WAY | ||||||||
Address2: |   | ||||||||
City: | PALO ALTO | ||||||||
State: | CA | ||||||||
PostalCode: | 943064010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4086426073 | ||||||||
FaxNumber: | 4086426076 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/05/2022 | ||||||||
LastUpdateDate: | 05/05/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DEWITT | ||||||||
AuthorizedOfficialFirstName: | KEVIN 'DEE' | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER-CFO | ||||||||
AuthorizedOfficialTelephone: | 4086426053 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/20/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |   | 171M00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator |   | 106H00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
No ID Information.