Healthcare Provider Details

I. General information

NPI: 1396480638
Provider Name (Legal Business Name): MISSIONARIES TO MINISTERS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2022
Last Update Date: 05/02/2022
Certification Date: 05/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 S WINCHESTER BLVD STE H187
SAN JOSE CA
95128-3903
US

IV. Provider business mailing address

1101 S WINCHESTER BLVD STE H187
SAN JOSE CA
95128-3903
US

V. Phone/Fax

Practice location:
  • Phone: 408-890-6306
  • Fax: 408-890-6246
Mailing address:
  • Phone: 408-890-6306
  • Fax: 408-890-6246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MR. TRACY SHANE COUCH
Title or Position: PRESIDENT/CO-FOUNDER
Credential: MA
Phone: 408-890-6306