Basic Information
Provider Information | |||||||||
NPI: | 1790801116 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COUNTY OF DEL NORTE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | DHHS BEHAVIORAL HEALTH BRANCH | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 455 K STREET | ||||||||
Address2: |   | ||||||||
City: | CRESCENT CITY | ||||||||
State: | CA | ||||||||
PostalCode: | 955318301 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7074647224 | ||||||||
FaxNumber: | 7074650855 | ||||||||
Practice Location | |||||||||
Address1: | 405 & 455 K STREET | ||||||||
Address2: |   | ||||||||
City: | CRESCENT CITY | ||||||||
State: | CA | ||||||||
PostalCode: | 955318301 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7074647224 | ||||||||
FaxNumber: | 7074650855 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/21/2007 | ||||||||
LastUpdateDate: | 05/13/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PADILLA | ||||||||
AuthorizedOfficialFirstName: | MARCUS | ||||||||
AuthorizedOfficialMiddleName: | T | ||||||||
AuthorizedOfficialTitleorPosition: | STAFF SERVICES ANALYST | ||||||||
AuthorizedOfficialTelephone: | 7074647224 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | COUNTY OF DEL NORTE | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 0801 | CA | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 0801 | 01 | CA | MEDICAL PROVIDER | OTHER |