Provider Demographics
NPI:1336815364
Name:CARDENAS, CAROLINE SUSY
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:SUSY
Last Name:CARDENAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 COLEMAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95110-1534
Mailing Address - Country:US
Mailing Address - Phone:408-277-1821
Mailing Address - Fax:
Practice Address - Street 1:909 COLEMAN AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95110-1534
Practice Address - Country:US
Practice Address - Phone:408-277-1821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-19
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105338101YM0800X
CA4354211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health