Provider Demographics
NPI:1194172122
Name:WILLOW GLEN HIGH
Entity type:Organization
Organization Name:WILLOW GLEN HIGH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LOREN
Authorized Official - Middle Name:
Authorized Official - Last Name:GISSIBLE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:408-287-6200
Mailing Address - Street 1:2001 COTTLE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95125-3502
Mailing Address - Country:US
Mailing Address - Phone:408-287-6200
Mailing Address - Fax:
Practice Address - Street 1:160 E VIRGINIA ST STE 280
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-5817
Practice Address - Country:US
Practice Address - Phone:408-287-6200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GARDNER FAMILY CARE CORPORATIO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-19
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health