Basic Information
| Provider Information | |||||||||
| NPI: | 1053540195 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DALY CITY YOUTH HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2780 JUNIPERO SERRA BLVD | ||||||||
| Address2: | |||||||||
| City: | DALY CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940151634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6509857000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2780 JUNIPERO SERRA BLVD | ||||||||
| Address2: | |||||||||
| City: | DALY CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940151634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6509857000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2009 | ||||||||
| LastUpdateDate: | 07/10/2009 | ||||||||
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| AuthorizedOfficialLastName: | STULLMAN | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
| AuthorizedOfficialMiddleName: | MITCHELL | ||||||||
| AuthorizedOfficialTitleorPosition: | MFTI | ||||||||
| AuthorizedOfficialTelephone: | 6505507678 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 58560 | CA | Y | Agencies | Community/Behavioral Health |
No ID Information.