Healthcare Provider Details

I. General information

NPI: 1811657331
Provider Name (Legal Business Name): MEBRAT LIDIA TECKIE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2021
Last Update Date: 12/23/2021
Certification Date: 12/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 S ABEL ST APT 328
MILPITAS CA
95035-9043
US

IV. Provider business mailing address

1102 S ABEL ST APT 328
MILPITAS CA
95035-9043
US

V. Phone/Fax

Practice location:
  • Phone: 408-421-9899
  • Fax:
Mailing address:
  • Phone: 408-421-9899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number103824
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: