Healthcare Provider Details

I. General information

NPI: 1952288763
Provider Name (Legal Business Name): CATHERINE SANDA TJAJA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2025
Last Update Date: 08/21/2025
Certification Date: 08/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43030 NEWPORT DR
FREMONT CA
94538-6113
US

IV. Provider business mailing address

43030 NEWPORT DR
FREMONT CA
94538-6113
US

V. Phone/Fax

Practice location:
  • Phone: 510-656-1250
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number250223406
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: