Basic Information
Provider Information | |||||||||
NPI: | 1366934218 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHASE | ||||||||
FirstName: | AUSTIN | ||||||||
MiddleName: | JAMES | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | ACSW 98224 | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3940 | ||||||||
Address2: |   | ||||||||
City: | QUINCY | ||||||||
State: | CA | ||||||||
PostalCode: | 95971 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5302833330 | ||||||||
FaxNumber: | 5304587751 | ||||||||
Practice Location | |||||||||
Address1: | 702-130 RICHMOND ROAD E | ||||||||
Address2: |   | ||||||||
City: | SUSANVILLE | ||||||||
State: | CA | ||||||||
PostalCode: | 96130 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5302575644 | ||||||||
FaxNumber: | 5304587751 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/05/2018 | ||||||||
LastUpdateDate: | 12/02/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/02/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X |   |   | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 104100000X |   | CA | N |   | Behavioral Health & Social Service Providers | Social Worker |   |
No ID Information.