Basic Information
| Provider Information | |||||||||
| NPI: | 1013389725 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EDGEWOOD CENTER FOR CHILDREN AND FAMILIES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | EDGEWOOD CENTER FOR CHILDREN AND FAMILIES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 957 INDUSTRIAL RD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | SAN CARLOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940704151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6508326900 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 170 S SPRUCE AVE | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | SOUTH SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6505178220 | ||||||||
| FaxNumber: | 6505178239 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2015 | ||||||||
| LastUpdateDate: | 07/02/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GRAJEDA | ||||||||
| AuthorizedOfficialFirstName: | AMERICA | ||||||||
| AuthorizedOfficialMiddleName: | MARIA | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR QUALITY IMPROVEMENT | ||||||||
| AuthorizedOfficialTelephone: | 4156823175 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.