Provider Demographics
NPI:1841674579
Name:ETHEM, PEMBE (PSYD)
Entity type:Individual
Prefix:
First Name:PEMBE
Middle Name:
Last Name:ETHEM
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 VETERANS BLVD STE 107
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94063-1404
Mailing Address - Country:US
Mailing Address - Phone:650-204-4204
Mailing Address - Fax:
Practice Address - Street 1:617 VETERANS BLVD STE 107
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94063-1404
Practice Address - Country:US
Practice Address - Phone:650-204-4204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-13
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist