=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548060908
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTEGRAL LIFE PSYCHOLOGY AND EDUCATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2025
-----------------------------------------------------
Last Update Date | 03/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20688 4TH ST # 4
-----------------------------------------------------
City | SARATOGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95070-5894
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-541-8680
-----------------------------------------------------
Fax | 833-806-7237
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2243 CHERRYSTONE DR
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95128-1219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-541-8680
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | BRIAN W TIERNEY
-----------------------------------------------------
Credential | PHD, LP
-----------------------------------------------------
Telephone | 510-541-8680
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------