Basic Information
| Provider Information | |||||||||
| NPI: | 1972711588 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTY OF SAN BERNARDINO | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | LUCERNE VALLEY COUNSELING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 268 W HOSPITALITY LANE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924150026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093823080 | ||||||||
| FaxNumber: | 9093823105 | ||||||||
| Practice Location | |||||||||
| Address1: | 32700 OLD WOMAN SPRINGS ROAD | ||||||||
| Address2: | SUITE C | ||||||||
| City: | LUCERNE VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093823080 | ||||||||
| FaxNumber: | 9093823105 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2007 | ||||||||
| LastUpdateDate: | 09/24/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DAY | ||||||||
| AuthorizedOfficialFirstName: | MICHALE | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | INFORMATION TECHNOLOGY MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9093880570 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DEPARTMENT OF BEHAVIORAL HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | ZZZ74743Z | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 3600036BY | 01 | CA | MEDICAL PROVIDER NUMBER | OTHER |