MEDICARE: SAN MATEO COUNTY HEALTH SYSTEM BHRS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QC1500X	Community Health Clinic/Center		CA

General Provider Information

NPI Number	:	1093025165
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN MATEO COUNTY HEALTH SYSTEM BHRS

Provider Business Mailing Address
First Line	:	2415 UNIVERSITY AVE STE 3
Second Line	:
City	:	EAST PALO ALTO
State	:	CA
Zip	:	94303-1148
Country	:	US
Telephone Number	:	650-363-4030
Fax Number	:

Provider Business Practice Location Address
First Line	:	2415 UNIVERSITY AVE STE 3
Second Line	:
City	:	EAST PALO ALTO
State	:	CA
Zip	:	94303-1148
Country	:	US
Telephone Number	:	650-363-4030
Fax Number	:

Authorized Official
Title or Position	:	MENTAL HEALTH COUNSELOR
Name	:	TALISHA RACY
Credential	:
Telephone Number	:	650-363-7871

Provider Enumeration Date	:	10/07/2010
Last Update Date	:	10/07/2010

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