Basic Information
| Provider Information | |||||||||
| NPI: | 1871910166 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAIN | ||||||||
| FirstName: | DESIREE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MISS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 714 WEST MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | GRASS VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5304779800 | ||||||||
| FaxNumber: | 5304779803 | ||||||||
| Practice Location | |||||||||
| Address1: | 714 WEST MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | GRASS VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5304779800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2014 | ||||||||
| LastUpdateDate: | 03/17/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X | N | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.