Provider Demographics
NPI:1538675525
Name:MARRIAGE AND FAMILY THERAPY COLLABORATIVE A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:MARRIAGE AND FAMILY THERAPY COLLABORATIVE A PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:TRICIA
Authorized Official - Middle Name:JORDAN
Authorized Official - Last Name:MLNARIK
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:408-207-5269
Mailing Address - Street 1:545 MERIDIAN AVENUE
Mailing Address - Street 2:STE. D #28233
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126-6618
Mailing Address - Country:US
Mailing Address - Phone:408-207-5269
Mailing Address - Fax:
Practice Address - Street 1:1570 THE ALAMEDA STE 319
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-2305
Practice Address - Country:US
Practice Address - Phone:408-207-5269
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-28
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1023464385Medicaid
CA1275666117Medicaid