Basic Information
| Provider Information | |||||||||
| NPI: | 1851793046 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTY OF DEL NORTE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DEPARTMENT OF HEALTH AND HUMAN SERVICES ALCOHOL AND OTHER DRUG | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1279 2ND ST STE C | ||||||||
| Address2: | |||||||||
| City: | CRESCENT CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955314134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074644813 | ||||||||
| FaxNumber: | 7074651442 | ||||||||
| Practice Location | |||||||||
| Address1: | 1279 2ND ST STE C | ||||||||
| Address2: | |||||||||
| City: | CRESCENT CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955314134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074640860 | ||||||||
| FaxNumber: | 7074650855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2014 | ||||||||
| LastUpdateDate: | 09/19/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CUMBRA | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PROGRAM COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 7074644813 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CADC-II | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.