Basic Information
| Provider Information | |||||||||
| NPI: | 1699219881 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOOTHILL COMMUNITY HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1650 S WHITE RD | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951274758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4089285250 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1650 S WHITE RD | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951274758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4089285250 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2016 | ||||||||
| LastUpdateDate: | 12/07/2016 | ||||||||
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| AuthorizedOfficialLastName: | HICKEY | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | DANIEL | ||||||||
| AuthorizedOfficialTitleorPosition: | BEHAVIORAL HEALTH CLINICIAN II | ||||||||
| AuthorizedOfficialTelephone: | 4087553905 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LMFT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | 46836 | CA | N | Agencies | Case Management | 251S00000X | 46836 | CA | Y | Agencies | Community/Behavioral Health |
No ID Information.