Basic Information
| Provider Information | |||||||||
| NPI: | 1285828871 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MT. DIABLO UNIFIED SCHOOL DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MT DIABLO USD WRAPAROUND AND COUNSELING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2400 LISA LN | ||||||||
| Address2: | |||||||||
| City: | PLEASANT HILL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945233902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9252506250 | ||||||||
| FaxNumber: | 9256824561 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 LISA LN | ||||||||
| Address2: | |||||||||
| City: | PLEASANT HILL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945233902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9252506250 | ||||||||
| FaxNumber: | 9256824561 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2007 | ||||||||
| LastUpdateDate: | 03/18/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOVE | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CLINIC COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 9252506250 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251300000X | Y | Agencies | Local Education Agency (LEA) |
ID Information
| ID | Type | State | Issuer | Description | SS0761754 | 05 | CA | MEDICAID |