MEDICARE: ADELINA ALVAREZ JOHNSON

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	1041C0700X	Clinical Social Worker	LCS21396	CA

General Provider Information

NPI Number	:	1164621389
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ADELINA ALVAREZ JOHNSON

Provider Business Mailing Address
First Line	:	150 W HEDDING ST
Second Line	:	CUSTODY MENTAL HEALTH
City	:	SAN JOSE
State	:	CA
Zip	:	95110-1706
Country	:	US
Telephone Number	:	408-808-5221
Fax Number	:

Provider Business Practice Location Address
First Line	:	150 W HEDDING ST
Second Line	:	CUSTODY MENTAL HEALTH
City	:	SAN JOSE
State	:	CA
Zip	:	95110-1706
Country	:	US
Telephone Number	:	408-808-5221
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/17/2007
Last Update Date	:	10/12/2007

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