Healthcare Provider Details

I. General information

NPI: 1922337864
Provider Name (Legal Business Name): KAISER PERMANENTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2009
Last Update Date: 12/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1761 BROADWAY ST 100
VALLEJO CA
94589-2226
US

IV. Provider business mailing address

1761 BROADWAY ST 100
VALLEJO CA
94589
US

V. Phone/Fax

Practice location:
  • Phone: 707-645-2700
  • Fax: 707-645-2181
Mailing address:
  • Phone: 707-645-2700
  • Fax: 707-645-2181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberMFC 47228
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberMFC 47228
License Number StateCA

VIII. Authorized Official

Name: TRACIE LEE KEPLER HOFFMAN
Title or Position: MFT
Credential:
Phone: 707-645-2700