Healthcare Provider Details

I. General information

NPI: 1750445094
Provider Name (Legal Business Name): KAISER PERMANENTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 05/05/2021
Certification Date: 05/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MUIR RD
MARTINEZ CA
94553-4614
US

IV. Provider business mailing address

206 LA BREA ST
VALLEJO CA
94591-8204
US

V. Phone/Fax

Practice location:
  • Phone: 707-558-8991
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCS13038
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberLCS13038
License Number StateCA

VIII. Authorized Official

Name: STUART BUTTLAIRE
Title or Position: DIRECTOR, INPATIENT SERVICES
Credential: PH. D.
Phone: 925-372-1103