Healthcare Provider Details

I. General information

NPI: 1053821355
Provider Name (Legal Business Name): LGTC GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2017
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2542 S BASCOM AVE STE 110
CAMPBELL CA
95008-5541
US

IV. Provider business mailing address

2542 S BASCOM AVE STE 110
CAMPBELL CA
95008-5541
US

V. Phone/Fax

Practice location:
  • Phone: 408-559-3403
  • Fax: 408-559-3158
Mailing address:
  • Phone: 800-913-2615
  • Fax: 408-559-3158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: EUGENE TILMAN
Title or Position: MANAGER
Credential:
Phone: 800-913-2615