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General NPI Number Information
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NPI Number | 1740022235
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Entity Type | Organization
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Legal Business Name | AGERE TRAUMA WORK PSC
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Dates
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Enumeration Date | 06/07/2024
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Last Update Date | 06/07/2024
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Provider Practice Location Address
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Address Line | 2033 GATEWAY PL UNIT 664
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City | SAN JOSE
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State | CA
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Zip | 95110-3709
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Country | US
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Telephone | 408-758-0805
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Fax |
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Provider Business Mailing Address
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Address Line | 3203 EVERDALE DR
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City | SAN JOSE
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State | CA
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Zip | 95148-3406
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Country | US
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Telephone | 408-758-0805
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Fax |
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Authorized Official
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Title or Position | OWNER/CEO
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Name | DIANE NGOC NGUYEN
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Credential | LMFT
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Telephone | 408-758-0805
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State |
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