Healthcare Provider Details

I. General information

NPI: 1083559314
Provider Name (Legal Business Name): DISRUPTIVE THERAPY COLLECTIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2026
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1769 PARK AVE STE 250
SAN JOSE CA
95126-2030
US

IV. Provider business mailing address

1769 PARK AVE STE 250
SAN JOSE CA
95126-2030
US

V. Phone/Fax

Practice location:
  • Phone: 408-365-4238
  • Fax:
Mailing address:
  • Phone: 408-365-4238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: ALICE BUI
Title or Position: CEO
Credential: LMFT
Phone: 408-365-4238