Basic Information
| Provider Information | |||||||||
| NPI: | 1740314855 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FRED FINCH YOUTH CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FRED FINCH YOUTH CENTER- BRIDGES OF SAN MATEO | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 126 W 25TH AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SAN MATEO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 944032208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6502862090 | ||||||||
| FaxNumber: | 6502862092 | ||||||||
| Practice Location | |||||||||
| Address1: | 126 W 25TH AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SAN MATEO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 944032208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6502862090 | ||||||||
| FaxNumber: | 6502862092 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2007 | ||||||||
| LastUpdateDate: | 09/23/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | ALEXANDER | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 5104822244 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC2200X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.