Healthcare Provider Details

I. General information

NPI: 1487673596
Provider Name (Legal Business Name): RICHARD BEAVER PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 HOSPITAL PKWY SUITE 470
SAN JOSE CA
95119-1106
US

IV. Provider business mailing address

275 HOSPITAL PKWY SUITE 470
SAN JOSE CA
95119-1106
US

V. Phone/Fax

Practice location:
  • Phone: 408-972-3364
  • Fax: 408-972-6088
Mailing address:
  • Phone: 408-972-3364
  • Fax: 408-972-6088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number20328
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number1565
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: