Basic Information
| Provider Information | |||||||||
| NPI: | 1386749091 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTY OF INYO | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | INYO COUNTY BEHAVIORAL HEATLH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1360 N MAIN ST STE 124 | ||||||||
| Address2: | |||||||||
| City: | BISHOP | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935143013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7608736533 | ||||||||
| FaxNumber: | 7608733277 | ||||||||
| Practice Location | |||||||||
| Address1: | 1360 N MAIN ST STE 124 | ||||||||
| Address2: | |||||||||
| City: | BISHOP | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935143013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7608736533 | ||||||||
| FaxNumber: | 7608733277 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 09/23/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | POPE | ||||||||
| AuthorizedOfficialFirstName: | CHRYSTINA | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | HEAD OF SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 7608722590 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LMFT | ||||||||
| NPICertificationDate: | 09/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | ZZT11964F | 01 | CA | MEDICAL | OTHER |