Healthcare Provider Details

I. General information

NPI: 1285764845
Provider Name (Legal Business Name): MS. MARY REDEMPTA MACAVORAY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 03/28/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 N WHITE RD
SAN JOSE CA
95127-1439
US

IV. Provider business mailing address

1922 THE ALAMEDA STE 316
SAN JOSE CA
95126-1461
US

V. Phone/Fax

Practice location:
  • Phone: 408-269-0760
  • Fax: 408-642-6052
Mailing address:
  • Phone: 408-261-7777
  • Fax: 408-642-6052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number35027
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: