Healthcare Provider Details

I. General information

NPI: 1124671524
Provider Name (Legal Business Name): MARILYN GRAHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2019
Last Update Date: 07/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 E VIRGINIA ST STE 100
SAN JOSE CA
95112-5865
US

IV. Provider business mailing address

160 E VIRGINIA ST STE 100
SAN JOSE CA
95112-5865
US

V. Phone/Fax

Practice location:
  • Phone: 408-287-6200
  • Fax: 408-579-6131
Mailing address:
  • Phone: 408-287-6200
  • Fax: 408-579-6131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMSC-52619
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: