Healthcare Provider Details

I. General information

NPI: 1356675763
Provider Name (Legal Business Name): MS. STEPHANIE CHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2009
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 THE ALAMEDA
SAN JOSE CA
95126-1136
US

IV. Provider business mailing address

1467 DENTWOOD DR
SAN JOSE CA
95118-2919
US

V. Phone/Fax

Practice location:
  • Phone: 408-261-7777
  • Fax: 408-254-9960
Mailing address:
  • Phone: 408-440-1802
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP2697
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: