Provider Demographics
NPI:1740022235
Name:AGERE TRAUMA WORK PSC
Entity type:Organization
Organization Name:AGERE TRAUMA WORK PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:NGOC
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:408-758-0805
Mailing Address - Street 1:3203 EVERDALE DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95148-3406
Mailing Address - Country:US
Mailing Address - Phone:408-758-0805
Mailing Address - Fax:
Practice Address - Street 1:2033 GATEWAY PL UNIT 664
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95110-3709
Practice Address - Country:US
Practice Address - Phone:408-758-0805
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-07
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty