Healthcare Provider Details

I. General information

NPI: 1275427007
Provider Name (Legal Business Name): TERESA MARIE KOTSOVOLOS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2025
Last Update Date: 06/05/2025
Certification Date: 06/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

631 RIVER OAKS PKWY
SAN JOSE CA
95134-1907
US

IV. Provider business mailing address

1111 W EL CAMINO REAL STE 133-237
SUNNYVALE CA
94087-1056
US

V. Phone/Fax

Practice location:
  • Phone: 408-914-7478
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: