Provider Demographics
NPI:1821023631
Name:PEARSON, CONNIE J (MA MFT)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:J
Last Name:PEARSON
Suffix:
Gender:F
Credentials:MA MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1646 PUERTO VALLARTA DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95120-4856
Mailing Address - Country:US
Mailing Address - Phone:408-268-2128
Mailing Address - Fax:408-268-2128
Practice Address - Street 1:1131 LUCHESSI DR
Practice Address - Street 2:SUITE 4
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95118-3770
Practice Address - Country:US
Practice Address - Phone:408-268-2128
Practice Address - Fax:408-268-2128
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC19077106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist