MEDICARE: ASSEFA TAYE DESTA

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	104100000X	Social Worker

General Provider Information

NPI Number	:	1518116078
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ASSEFA TAYE DESTA

Provider Business Mailing Address
First Line	:	4774 CAMPBELL AVE UNIT 12
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95130-1857
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4774 CAMPBELL AVE UNIT 12
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95130-1857
Country	:	US
Telephone Number	:	408-379-9938
Fax Number	:

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

Provider Enumeration Date	:	09/09/2008
Last Update Date	:	09/09/2008

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