Healthcare Provider Details

I. General information

NPI: 1659072965
Provider Name (Legal Business Name): SANTA CLARA COUNTY SUBSTANCE ABUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2023
Last Update Date: 03/14/2023
Certification Date: 03/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8339 CHURCH ST STE 217
GILROY CA
95020-4450
US

IV. Provider business mailing address

8339 CHURCH ST STE 217
GILROY CA
95020-4450
US

V. Phone/Fax

Practice location:
  • Phone: 650-921-2261
  • Fax:
Mailing address:
  • Phone: 650-921-2261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name: ASHLEY NICOLE FOSTER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 650-921-2261