Healthcare Provider Details

I. General information

NPI: 1134307507
Provider Name (Legal Business Name): MARIA CHARISMA SIDECO LICERALDE APRN, PMHNP, BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2008
Last Update Date: 02/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 GREAT OAKS BLVD
SAN JOSE CA
95119-1310
US

IV. Provider business mailing address

80 GREAT OAKS BLVD
SAN JOSE CA
95119-1310
US

V. Phone/Fax

Practice location:
  • Phone: 408-363-3000
  • Fax: 408-363-3046
Mailing address:
  • Phone: 408-363-3000
  • Fax: 408-363-3046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number715901
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: