Healthcare Provider Details

I. General information

NPI: 1487565966
Provider Name (Legal Business Name): MARY JOHANNA CARVAJAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5511 WALNUT BLOSSOM DR APT 15
SAN JOSE CA
95123-2234
US

IV. Provider business mailing address

5511 WALNUT BLOSSOM DR APT 15
SAN JOSE CA
95123-2234
US

V. Phone/Fax

Practice location:
  • Phone: 408-981-7835
  • Fax:
Mailing address:
  • Phone: 408-981-7835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-535618
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: