Healthcare Provider Details

I. General information

NPI: 1770645939
Provider Name (Legal Business Name): GARY JAMES REZOWALLI PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 BERNAL RD STE 140
SAN JOSE CA
95119-1343
US

IV. Provider business mailing address

175 BERNAL RD STE 140
SAN JOSE CA
95119-1343
US

V. Phone/Fax

Practice location:
  • Phone: 408-972-6454
  • Fax: 408-972-6494
Mailing address:
  • Phone: 408-972-6454
  • Fax: 408-972-6494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY 13273
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: