Provider Demographics
NPI:1316083884
Name:SOUTH BAY COMMUNITY COUNSELING CENTER
Entity type:Organization
Organization Name:SOUTH BAY COMMUNITY COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CLIFFORD
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:BROTHERS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:408-271-8558
Mailing Address - Street 1:1101 S WINCHESTER BLVD BLDG O SUITE 284
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128
Mailing Address - Country:US
Mailing Address - Phone:408-271-8558
Mailing Address - Fax:408-248-8260
Practice Address - Street 1:1101 S WINCHESTER BLVD BLDG O SUITE 284
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128
Practice Address - Country:US
Practice Address - Phone:408-271-8558
Practice Address - Fax:408-248-8260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
22224909ZMedicare ID - Type Unspecified