Basic Information
| Provider Information | |||||||||
| NPI: | 1497085138 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CANYON OAKS YOUTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9031 CASTLEWOOD ST | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946054407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102132592 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 EDMONDS RD | ||||||||
| Address2: | |||||||||
| City: | REDWOOD CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940623803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6508391810 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/31/2009 | ||||||||
| LastUpdateDate: | 12/31/2009 | ||||||||
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| AuthorizedOfficialLastName: | HOLECHEK | ||||||||
| AuthorizedOfficialFirstName: | TIM | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | RESIDENTAL COUNSELOR RELIEF | ||||||||
| AuthorizedOfficialTelephone: | 6508391810 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
No ID Information.