Healthcare Provider Details

I. General information

NPI: 1548139181
Provider Name (Legal Business Name): RICHARD TJANDRA
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2025
Last Update Date: 11/07/2025
Certification Date: 11/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 MOORPARK AVE STE 120
SAN JOSE CA
95117-1707
US

IV. Provider business mailing address

PO BOX 934
PLEASANTON CA
94566-0093
US

V. Phone/Fax

Practice location:
  • Phone: 408-320-5960
  • Fax:
Mailing address:
  • Phone: 925-307-7884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number149900
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: