Basic Information
| Provider Information | |||||||||
| NPI: | 1710249461 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEPATMENT OF BEHAVIORAL HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 E COOLEY DR | ||||||||
| Address2: | |||||||||
| City: | COLTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923243905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094230750 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1300 E COOLEY DR | ||||||||
| Address2: | |||||||||
| City: | COLTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923243905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094230750 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2012 | ||||||||
| LastUpdateDate: | 06/08/2012 | ||||||||
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| AuthorizedOfficialLastName: | OLSEN | ||||||||
| AuthorizedOfficialFirstName: | ELLEN | ||||||||
| AuthorizedOfficialMiddleName: | BRIDGET | ||||||||
| AuthorizedOfficialTitleorPosition: | LICENSED PSYCHIATRIC TECHNICIAN | ||||||||
| AuthorizedOfficialTelephone: | 9095986462 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | L.P.T. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 284300000X | 32634 | CA | Y | Hospitals | Special Hospital |
No ID Information.