Healthcare Provider Details

I. General information

NPI: 1821023631
Provider Name (Legal Business Name): CONNIE J PEARSON MA MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1131 LUCHESSI DR SUITE 4
SAN JOSE CA
95118-3770
US

IV. Provider business mailing address

1646 PUERTO VALLARTA DR
SAN JOSE CA
95120-4856
US

V. Phone/Fax

Practice location:
  • Phone: 408-268-2128
  • Fax: 408-268-2128
Mailing address:
  • Phone: 408-268-2128
  • Fax: 408-268-2128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC19077
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: