Basic Information
| Provider Information | |||||||||
| NPI: | 1750452199 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CRESTWOOD BEHAVIORAL HEALTH, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | OUR HOUSE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7590 SHORELINE DR | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952195455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2099552328 | ||||||||
| FaxNumber: | 2099525314 | ||||||||
| Practice Location | |||||||||
| Address1: | 2201 TUOLUMNE ST | ||||||||
| Address2: | |||||||||
| City: | VALLEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945892524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075581777 | ||||||||
| FaxNumber: | 7075581770 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2006 | ||||||||
| LastUpdateDate: | 05/19/2015 | ||||||||
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| AuthorizedOfficialLastName: | BLACKBURN | ||||||||
| AuthorizedOfficialFirstName: | LORI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2099552322 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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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.