Basic Information
Provider Information | |||||||||
NPI: | 1497494934 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EDGEWOOD CENTER FOR CHILDREN & FAMILIES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | EDGEWOOD CENTER FOR CHILDREN & FAMILIES - CRISIS STABILIZATION UNIT | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1801 VICENTE ST | ||||||||
Address2: |   | ||||||||
City: | SAN FRANCISCO | ||||||||
State: | CA | ||||||||
PostalCode: | 941162923 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4156823175 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2681 28TH AVE | ||||||||
Address2: |   | ||||||||
City: | SAN FRANCISCO | ||||||||
State: | CA | ||||||||
PostalCode: | 941162912 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4156823175 | ||||||||
FaxNumber: | 4156647094 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/02/2022 | ||||||||
LastUpdateDate: | 08/10/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GRAJEDA | ||||||||
AuthorizedOfficialFirstName: | AMERICA | ||||||||
AuthorizedOfficialMiddleName: | MARIA | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR QUALITY IMPROVEMENT | ||||||||
AuthorizedOfficialTelephone: | 4156823175 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/10/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
No ID Information.