1043340003 NPI number — MS. MELODIE KENNA TUBIS MSW, LCSW

Table of content: MS. MELODIE KENNA TUBIS MSW, LCSW (NPI 1043340003)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043340003 NPI number — MS. MELODIE KENNA TUBIS MSW, LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TUBIS
Provider First Name:
MELODIE
Provider Middle Name:
KENNA
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MSW, LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MONROE
Provider Other First Name:
MELODIE
Provider Other Middle Name:
KENNA
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1043340003
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1207 MINNESOTA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN JOSE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95125-3839
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
408-209-2117
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1993 MCKEE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN JOSE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95116-1406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
408-926-7950
Provider Business Practice Location Address Fax Number:
408-926-7997
Provider Enumeration Date:
03/07/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  ASW 13702 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 24657 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)