Basic Information
| Provider Information | |||||||||
| NPI: | 1538477948 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MOMENTUM FOR MENTAL HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1233 FOOTHILL ST | ||||||||
| Address2: | |||||||||
| City: | REDWOOD CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940611918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4157301892 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2001 THE ALAMEDA | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951261136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082617777 | ||||||||
| FaxNumber: | 4082549960 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2010 | ||||||||
| LastUpdateDate: | 09/20/2010 | ||||||||
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| AuthorizedOfficialLastName: | DITIBERIO | ||||||||
| AuthorizedOfficialFirstName: | ANNE | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINICIAN I | ||||||||
| AuthorizedOfficialTelephone: | 4082546828 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | ASW, PPSC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | ASW28279 | CA | Y | Agencies | Community/Behavioral Health |
No ID Information.