Provider Demographics
NPI:1609106608
Name:NORMAN, ROYAL ANTHONY SR (RAS)
Entity Type:Individual
Prefix:MR
First Name:ROYAL
Middle Name:ANTHONY
Last Name:NORMAN
Suffix:SR
Gender:M
Credentials:RAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 N 4TH ST
Mailing Address - Street 2:STE 100
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112-5569
Mailing Address - Country:US
Mailing Address - Phone:408-295-5288
Mailing Address - Fax:408-292-1022
Practice Address - Street 1:210 N 4TH ST
Practice Address - Street 2:STE 100
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-5569
Practice Address - Country:US
Practice Address - Phone:408-295-5288
Practice Address - Fax:408-292-1022
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-13
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAN0312291432101Y00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ00543ZMedicare PIN