Basic Information
| Provider Information | |||||||||
| NPI: | 1366097107 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COUNTY OF TRINITY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1640 | ||||||||
| Address2: | |||||||||
| City: | WEAVERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960931640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306231362 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1450 MAIN ST. | ||||||||
| Address2: | |||||||||
| City: | WEAVERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960931640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306231362 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2019 | ||||||||
| LastUpdateDate: | 08/08/2019 | ||||||||
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| AuthorizedOfficialLastName: | MANDOLFO | ||||||||
| AuthorizedOfficialFirstName: | AMBER | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMIN. SPECAILIST | ||||||||
| AuthorizedOfficialTelephone: | 5306231922 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.