Provider Demographics
NPI:1538698949
Name:COULTER, MICHAEL BRIAN
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BRIAN
Last Name:COULTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1144 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112-5974
Mailing Address - Country:US
Mailing Address - Phone:408-843-7738
Mailing Address - Fax:
Practice Address - Street 1:1144 S 2ND ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-5974
Practice Address - Country:US
Practice Address - Phone:408-843-7738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2025-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1015231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA101YM0800XMedicaid