Provider Demographics
NPI:1821215112
Name:MOMENTUM FOR MENTAL HEALTH- ISP & FSP
Entity Type:Organization
Organization Name:MOMENTUM FOR MENTAL HEALTH- ISP & FSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:S
Authorized Official - Last Name:SMELSER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-261-7777
Mailing Address - Street 1:2001 THE ALAMEDA
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126-1136
Mailing Address - Country:US
Mailing Address - Phone:408-261-7777
Mailing Address - Fax:408-554-9960
Practice Address - Street 1:150 S AUTUMN ST STE A
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95110-2515
Practice Address - Country:US
Practice Address - Phone:408-938-6750
Practice Address - Fax:408-977-0145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0000043ARMedicaid
CAZZZ01125ZMedicare ID - Type UnspecifiedMEDICARE IDENTIFICATION