Basic Information
| Provider Information | |||||||||
| NPI: | 1164638334 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TEHAMA COUNTY HEALTH SERVICES AGENCY MENTAL HEALTH DIVISION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 400 | ||||||||
| Address2: | |||||||||
| City: | RED BLUFF | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960800400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305278491 | ||||||||
| FaxNumber: | 5305270240 | ||||||||
| Practice Location | |||||||||
| Address1: | 1445 VISTA WAY | ||||||||
| Address2: | |||||||||
| City: | RED BLUFF | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960804510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305278491 | ||||||||
| FaxNumber: | 5305270240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2007 | ||||||||
| LastUpdateDate: | 09/02/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LUCERO | ||||||||
| AuthorizedOfficialFirstName: | VALERIE | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5305278491 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TEHAMA COUNTY | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | 09/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QM0855X | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 000005248 | 05 | CA | MEDICAID |