Healthcare Provider Details

I. General information

NPI: 1871269472
Provider Name (Legal Business Name): GHAIDAA MOUSABACHA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2021
Last Update Date: 03/12/2024
Certification Date: 03/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 MOORPARK AVE STE 300
SAN JOSE CA
95128-2680
US

IV. Provider business mailing address

2400 MOORPARK AVE STE 300
SAN JOSE CA
95128-2680
US

V. Phone/Fax

Practice location:
  • Phone: 408-975-2730
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberLCS27878
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS27878
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: