Basic Information
| Provider Information | |||||||||
| NPI: | 1285913590 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KAISER PERMANENTE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7373 WEST LN | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952103377 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 7373 WEST LN | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952103377 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094765115 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2011 | ||||||||
| LastUpdateDate: | 08/04/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SAMELSON | ||||||||
| AuthorizedOfficialFirstName: | DOREEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | BEHAVIORAL HEALTH MANAGER III | ||||||||
| AuthorizedOfficialTelephone: | 2098587754 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | EDD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302F00000X | 27250 | CA | Y | Managed Care Organizations | Exclusive Provider Organization |
No ID Information.