Basic Information
| Provider Information | |||||||||
| NPI: | 1659670008 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CATHLIC CHARITIES CYO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18 W LAKE DR | ||||||||
| Address2: | |||||||||
| City: | ANTIOCH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945091939 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 ST.VINCENT DR | ||||||||
| Address2: | |||||||||
| City: | SAN RAFAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4155072000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2011 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | THESIA | ||||||||
| AuthorizedOfficialMiddleName: | NICHELLE | ||||||||
| AuthorizedOfficialTitleorPosition: | PROGRAM SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 4155072000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X | CA | Y | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |
No ID Information.