Healthcare Provider Details

I. General information

NPI: 1659025013
Provider Name (Legal Business Name): LIBERTY CLAMUCHA CAJAYON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2022
Last Update Date: 02/04/2022
Certification Date: 02/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 ELM ST STE 212
SAN CARLOS CA
94070-3070
US

IV. Provider business mailing address

610 ELM ST STE 212
SAN CARLOS CA
94070-3070
US

V. Phone/Fax

Practice location:
  • Phone: 650-591-9623
  • Fax:
Mailing address:
  • Phone: 650-591-9623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: