Healthcare Provider Details

I. General information

NPI: 1881802080
Provider Name (Legal Business Name): ROBERTA BASSETT CORSON PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4010 MOORPARK AVE SUITE 206
SAN JOSE CA
95117-4101
US

IV. Provider business mailing address

4010 MOORPARK AVE SUITE 206
SAN JOSE CA
95117-4101
US

V. Phone/Fax

Practice location:
  • Phone: 408-247-1774
  • Fax:
Mailing address:
  • Phone: 408-247-1774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License NumberPSY18128
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY18128
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY18128
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: