Basic Information
| Provider Information | |||||||||
| NPI: | 1194034645 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CRESTWOOD BEHAVIORAL HEALTH, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | CRESTWOOD PSYCHIATRIC HEALTH FACILITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7590 SHORELINE DR | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952195455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2099552328 | ||||||||
| FaxNumber: | 2094449774 | ||||||||
| Practice Location | |||||||||
| Address1: | 6700 EUCALYPTUS DR STE C | ||||||||
| Address2: | |||||||||
| City: | BAKERSFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 933066075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6613638127 | ||||||||
| FaxNumber: | 6613639124 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2010 | ||||||||
| LastUpdateDate: | 04/29/2015 | ||||||||
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| AuthorizedOfficialLastName: | BLACKBURN | ||||||||
| AuthorizedOfficialFirstName: | LORI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2099552322 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X | Y | Hospitals | Psychiatric Hospital |
No ID Information.