Basic Information
Provider Information | |||||||||
NPI: | 1548488323 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COUNTY OF SUTTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SYBH (CHILDRENS SERVICES) | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1965 LIVE OAK BLVD STE C | ||||||||
Address2: | ATTN SYBH (CHILDRENS SERVICES) | ||||||||
City: | YUBA CITY | ||||||||
State: | CA | ||||||||
PostalCode: | 959918850 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5308227200 | ||||||||
FaxNumber: | 5308227514 | ||||||||
Practice Location | |||||||||
Address1: | 1445 VETERANS MEMORIAL CIR STE B | ||||||||
Address2: |   | ||||||||
City: | YUBA CITY | ||||||||
State: | CA | ||||||||
PostalCode: | 959933011 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5308227200 | ||||||||
FaxNumber: | 5308227514 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/24/2007 | ||||||||
LastUpdateDate: | 07/24/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BINGHAM | ||||||||
AuthorizedOfficialFirstName: | RICK | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ASSISTANT HHS DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 5308227327 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | COUNTY OF SUTTER | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LMFT | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
ID Information
ID | Type | State | Issuer | Description | 5809 | 01 | CA | SHORT-DOYLE MEDI-CAL | OTHER |