Provider Demographics
NPI:1538477948
Name:MOMENTUM FOR MENTAL HEALTH
Entity Type:Organization
Organization Name:MOMENTUM FOR MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICIAN I
Authorized Official - Prefix:
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:C
Authorized Official - Last Name:DITIBERIO
Authorized Official - Suffix:
Authorized Official - Credentials:ASW, PPSC
Authorized Official - Phone:408-254-6828
Mailing Address - Street 1:1233 FOOTHILL ST
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94061-1918
Mailing Address - Country:US
Mailing Address - Phone:415-730-1892
Mailing Address - Fax:
Practice Address - Street 1:2001 THE ALAMEDA
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-1136
Practice Address - Country:US
Practice Address - Phone:408-261-7777
Practice Address - Fax:408-254-9960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-20
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW28279251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health