Basic Information
Provider Information | |||||||||
NPI: | 1720165368 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CRESTWOOD BEHAVIORAL HEALTH, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FRUITRIDGE TRANSITIONAL HOME | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7590 SHORELINE DR | ||||||||
Address2: |   | ||||||||
City: | STOCKTON | ||||||||
State: | CA | ||||||||
PostalCode: | 952195455 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2099552328 | ||||||||
FaxNumber: | 2099525314 | ||||||||
Practice Location | |||||||||
Address1: | 4256 FRUITRIDGE RD | ||||||||
Address2: |   | ||||||||
City: | SACRAMENTO | ||||||||
State: | CA | ||||||||
PostalCode: | 958205047 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9164272363 | ||||||||
FaxNumber: | 9164292631 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/01/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BLACKBURN | ||||||||
AuthorizedOfficialFirstName: | LORI | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 2099552322 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X |   |   | Y |   | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |   |
No ID Information.