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General NPI Number Information
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NPI Number | 1902933476
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Entity Type | Organization
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Legal Business Name | KAISER SANTA THERESA PSYCHIATRY DEPT
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Dates
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Enumeration Date | 02/28/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 5755 COTTLE RD BUILDING 4
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City | SAN JOSE
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State | CA
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Zip | 95014
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Country | US
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Telephone | 408-972-3419
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Fax |
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Provider Business Mailing Address
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Address Line | P O BOX 5956
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City | SAN JOSE
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State | CA
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Zip | 95150
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Country | US
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Telephone | 408-972-3419
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Fax |
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Authorized Official
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Title or Position | THERAPIST
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Name | MS. SHANNON B MICHELSON
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Credential | LCSW
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Telephone | 408-972-3419
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | LCS21247
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License Number State | CA
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