Basic Information
| Provider Information | |||||||||
| NPI: | 1558434126 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VICTOR COMMUNITY SUPPORT SERVICES, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FAMILY INTERVENTION AND COMMUNITY SUPPORT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1952 HERSHEY DR | ||||||||
| Address2: | |||||||||
| City: | WOODLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 957765143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013619943 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 103 D ST | ||||||||
| Address2: | |||||||||
| City: | MARYSVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959016017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306713427 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MADAUS | ||||||||
| AuthorizedOfficialFirstName: | MATT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5306713427 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 20722 | CA | Y | Agencies | Community/Behavioral Health |
No ID Information.