Healthcare Provider Details

I. General information

NPI: 1790613222
Provider Name (Legal Business Name): KIM CHAVEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 2ND AVE
SAN MATEO CA
94401-3828
US

IV. Provider business mailing address

1045 CADILLAC WAY APT 108
BURLINGAME CA
94010-2525
US

V. Phone/Fax

Practice location:
  • Phone: 650-403-4300
  • Fax:
Mailing address:
  • Phone: 650-931-6300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberU0626218
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: