Provider Demographics
NPI:1831767888
Name:TA, MAE PEARL (AMFT, APCC)
Entity type:Individual
Prefix:
First Name:MAE
Middle Name:PEARL
Last Name:TA
Suffix:
Gender:F
Credentials:AMFT, APCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 SUNOL ST UNIT 336
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126-4380
Mailing Address - Country:US
Mailing Address - Phone:669-226-2100
Mailing Address - Fax:
Practice Address - Street 1:1835 PARK AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-1629
Practice Address - Country:US
Practice Address - Phone:303-989-8169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-16
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8808101YP2500X
CA122719106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional