Basic Information
| Provider Information | |||||||||
| NPI: | 1093920647 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EDGEWOOD CENTER FOR CHILDREN AND FAMILIES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EDGEWOOD CENTER FOR CHILDREN AND FAMILIES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1510 FASHION ISLAND BLVD STE 310 | ||||||||
| Address2: | |||||||||
| City: | SAN MATEO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 944041587 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6508326900 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1510 FASHION ISLAND BLVD STE 310 | ||||||||
| Address2: | |||||||||
| City: | SAN MATEO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 944041587 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6508326900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2007 | ||||||||
| LastUpdateDate: | 01/31/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GRAJEDA | ||||||||
| AuthorizedOfficialFirstName: | AMERICA | ||||||||
| AuthorizedOfficialMiddleName: | MARIA | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR QUALITY IMPROVEMENT | ||||||||
| AuthorizedOfficialTelephone: | 4156823175 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.