Basic Information
| Provider Information | |||||||||
| NPI: | 1952516031 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CITY OF SAN JOSE GRACE COMMUNITY CENTER WOMEN'S PROGRAM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 484 E SAN FERNANDO ST | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951123513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082930422 | ||||||||
| FaxNumber: | 4082772474 | ||||||||
| Practice Location | |||||||||
| Address1: | 146 S 10TH ST | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951123641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082930422 | ||||||||
| FaxNumber: | 4082772474 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BLEVINS | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4082930422 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | PSY14707 | CA | Y | Agencies | Community/Behavioral Health |
No ID Information.