Healthcare Provider Details

I. General information

NPI: 1376710871
Provider Name (Legal Business Name): SACKETT AFFILIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2008
Last Update Date: 05/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1745 SARATOGA AVE SUITE 203
SAN JOSE CA
95129-5201
US

IV. Provider business mailing address

1745 SARATOGA AVE SUITE 203
SAN JOSE CA
95129-5201
US

V. Phone/Fax

Practice location:
  • Phone: 408-257-6662
  • Fax:
Mailing address:
  • Phone: 408-257-6662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY18785
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number33627
License Number StateCA

VIII. Authorized Official

Name: BRIAN SACKETT
Title or Position: PRESIDENT/PSYCHOLOGIST
Credential: PH.D.
Phone: 408-257-6662