Basic Information
| Provider Information | |||||||||
| NPI: | 1871758896 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GRACE COMMUNITY CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 484 E SAN FERNANDO ST | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951123513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082930422 | ||||||||
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| Practice Location | |||||||||
| Address1: | 484 E SAN FERNANDO ST | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951123513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082930422 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2008 | ||||||||
| LastUpdateDate: | 07/21/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BLEVINS | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | THERAPEUTIC SERVICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4082930422 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CITY OF SAN JOSE | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 42502 | 01 | CA | PARCCA | OTHER |