Basic Information
| Provider Information | |||||||||
| NPI: | 1801930920 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH COUNTY MENTAL HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 EMELINE AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA CRUZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950601976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8314544971 | ||||||||
| FaxNumber: | 8314544663 | ||||||||
| Practice Location | |||||||||
| Address1: | 1430 FREEDOM BLVD | ||||||||
| Address2: | SUITE F | ||||||||
| City: | WATSONVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950762780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8317638200 | ||||||||
| FaxNumber: | 8314544663 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2007 | ||||||||
| LastUpdateDate: | 10/23/2019 | ||||||||
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| AuthorizedOfficialLastName: | RANDOLPH | ||||||||
| AuthorizedOfficialFirstName: | JESSICA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF ADMINISTRATION | ||||||||
| AuthorizedOfficialTelephone: | 8314544000 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COUNTY OF SANTA CRUZ | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | CA | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QM0850X | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1659315430 | 01 | CA | LEGAL ENTITY NPI# | OTHER | ZZZ91891Z | 01 | CA | COUNTY OF SANTA CRUZ MEDICARE GROUP PTAN# | OTHER | 4475 | 05 | CA | MEDICAID | FHC70044F | 01 | CA | SANTA CRUZ COUNTY MEDI-CAL GROUP NUNMBER | OTHER |