Healthcare Provider Details

I. General information

NPI: 1881351880
Provider Name (Legal Business Name): MARIAH MARCELLA HEIMSOTH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2021
Last Update Date: 02/22/2026
Certification Date: 02/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1302 N 4TH ST
SAN JOSE CA
95112-4713
US

IV. Provider business mailing address

37988 LOGAN DR
FREMONT CA
94536-5946
US

V. Phone/Fax

Practice location:
  • Phone: 408-379-3790
  • Fax:
Mailing address:
  • Phone: 510-456-8581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: