Basic Information
| Provider Information | |||||||||
| NPI: | 1871628578 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHANGING TIDES FAMILY SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HUMBOLDT CHILD CARE COUNCIL | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2259 MYRTLE AVE | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955013325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074448293 | ||||||||
| FaxNumber: | 7074448298 | ||||||||
| Practice Location | |||||||||
| Address1: | 2259 MYRTLE AVE | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955013325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074448293 | ||||||||
| FaxNumber: | 7074448298 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2007 | ||||||||
| LastUpdateDate: | 01/05/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SUNDBERG | ||||||||
| AuthorizedOfficialFirstName: | CONNIE | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, FAMILY EMPOWERMENT SERVIC | ||||||||
| AuthorizedOfficialTelephone: | 7074448293 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.