Healthcare Provider Details

I. General information

NPI: 1821215112
Provider Name (Legal Business Name): MOMENTUM FOR MENTAL HEALTH- ISP & FSP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 08/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 S AUTUMN ST STE A
SAN JOSE CA
95110-2515
US

IV. Provider business mailing address

2001 THE ALAMEDA
SAN JOSE CA
95126-1136
US

V. Phone/Fax

Practice location:
  • Phone: 408-938-6750
  • Fax: 408-977-0145
Mailing address:
  • Phone: 408-261-7777
  • Fax: 408-554-9960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: JOHN S SMELSER
Title or Position: CFO
Credential:
Phone: 408-261-7777