{
"Npi": {
"NPI": "1548060908",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "INTEGRAL LIFE PSYCHOLOGY AND EDUCATION",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "2243 CHERRYSTONE DR",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "SAN JOSE",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "95128-1219",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "510-541-8680",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "20688 4TH ST # 4",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "SARATOGA",
"PracticeLocationAddressStateName": "CA",
"PracticeLocationAddressPostalCode": "95070-5894",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "510-541-8680",
"PracticeLocationAddressFaxNumber": "833-806-7237",
"EnumerationDate": "03/15/2025",
"LastUpdateDate": "03/15/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "TIERNEY",
"AuthorizedOfficialFirstName": "BRIAN",
"AuthorizedOfficialMiddleName": "W",
"AuthorizedOfficialTitle": "PRESIDENT",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "PHD, LP",
"AuthorizedOfficialTelephoneNumber": "510-541-8680",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "103TC0700X",
"TaxonomyName": "Clinical Psychologist",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
}
}
}