Basic Information
| Provider Information | |||||||||
| NPI: | 1730721929 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAN MATEO COUNTY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ELYSIAN STRTP COUNTY OF SAN MATEO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 DAVIS DRIVE | ||||||||
| Address2: | ATTN: NATASHA BOURBONNAIS | ||||||||
| City: | BELMONT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6508026583 | ||||||||
| FaxNumber: | 6505923056 | ||||||||
| Practice Location | |||||||||
| Address1: | 31 TOWER RD | ||||||||
| Address2: | |||||||||
| City: | SAN MATEO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 944024000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6503125320 | ||||||||
| FaxNumber: | 6505722414 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2019 | ||||||||
| LastUpdateDate: | 08/25/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOURBONNAIS | ||||||||
| AuthorizedOfficialFirstName: | NATASHA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | HUMAN SERVICES MANAGER II | ||||||||
| AuthorizedOfficialTelephone: | 6508026583 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COUNTY OF SAN MATEO | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | 08/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X | Y | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |
No ID Information.