Provider Demographics
NPI:1407221948
Name:BAY AREA BEHAVIORAL GROUP
Entity Type:Organization
Organization Name:BAY AREA BEHAVIORAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:LAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-586-8654
Mailing Address - Street 1:4423 FORTRAN COURT, #136
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95134
Mailing Address - Country:US
Mailing Address - Phone:408-586-8654
Mailing Address - Fax:
Practice Address - Street 1:4423 FORTRAN COURT, #136
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95134
Practice Address - Country:US
Practice Address - Phone:408-586-8654
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-09
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health