MEDICARE: CONFIDENCE CLUB PSYCHOLOGY SERVICES, INC.

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	261QM0855X	Adolescent and Children Mental Health Clinic/Center

General Provider Information

NPI Number	:	1447082102
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONFIDENCE CLUB PSYCHOLOGY SERVICES, INC.

Provider Business Mailing Address
First Line	:	55 SANTA CLARA AVE STE 177
Second Line	:
City	:	OAKLAND
State	:	CA
Zip	:	94610-1333
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	55 SANTA CLARA AVE STE 177
Second Line	:
City	:	OAKLAND
State	:	CA
Zip	:	94610-1333
Country	:	US
Telephone Number	:	510-255-5141
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. KATYA EKMAN
Credential	:
Telephone Number	:	510-255-5141

Provider Enumeration Date	:	08/20/2024
Last Update Date	:	08/20/2024

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