Healthcare Provider Details

I. General information

NPI: 1225269525
Provider Name (Legal Business Name): RICHARD CHARLES WREN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2009
Last Update Date: 08/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

237 RACE ST
SAN JOSE CA
95126-4823
US

IV. Provider business mailing address

PO BOX 730276
SAN JOSE CA
95173-0276
US

V. Phone/Fax

Practice location:
  • Phone: 408-971-9822
  • Fax:
Mailing address:
  • Phone:
  • 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:
Title or Position:
Credential:
Phone: