Provider Demographics
NPI:1821692500
Name:PACKHAM, CHRIS MICHAEL (LAADC, WTS, CS)
Entity Type:Individual
Prefix:
First Name:CHRIS
Middle Name:MICHAEL
Last Name:PACKHAM
Suffix:
Gender:M
Credentials:LAADC, WTS, CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126-2911
Mailing Address - Country:US
Mailing Address - Phone:408-915-1321
Mailing Address - Fax:408-297-7450
Practice Address - Street 1:1101 PARK AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-2911
Practice Address - Country:US
Practice Address - Phone:408-915-1321
Practice Address - Fax:408-297-7450
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCI04620615101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty