Basic Information
| Provider Information | |||||||||
| NPI: | 1235630369 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WAVERLY PLACE APARTMENTS, LP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MENTAL HEALTH ASSOCIATION | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2686 SPRING ST | ||||||||
| Address2: | |||||||||
| City: | REDWOOD CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940633522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6503683345 | ||||||||
| FaxNumber: | 5108790354 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 WAVERLY PLACE | ||||||||
| Address2: | |||||||||
| City: | REDWOOD CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6503683345 | ||||||||
| FaxNumber: | 5108790354 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2018 | ||||||||
| LastUpdateDate: | 02/23/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | YOUNG | ||||||||
| AuthorizedOfficialFirstName: | SHANE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PROGRAM AND OPERATIONS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6502578816 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MENTAL HEALTH ASSOCIATION OF SAN MATEO COUNTY | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | Y | Agencies | Case Management |
No ID Information.