=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437353737
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VERCILA E. CHACON L.C.S.W.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2007
-----------------------------------------------------
Last Update Date | 11/20/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 370 S KING RD
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95116-3400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-318-2817
-----------------------------------------------------
Fax | 408-251-6987
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 370 S KING RD
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95116-3400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-318-2817
-----------------------------------------------------
Fax | 408-251-6987
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LCS17841
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------