Basic Information
Provider Information | |||||||||
NPI: | 1972755296 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RIVERSIDE COUNTY - HEMET MENTAL HEALTH SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 19417 ROTTERDAM | ||||||||
Address2: |   | ||||||||
City: | RIVERSIDE | ||||||||
State: | CA | ||||||||
PostalCode: | 925086179 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 650 N STATE ST | ||||||||
Address2: |   | ||||||||
City: | HEMET | ||||||||
State: | CA | ||||||||
PostalCode: | 925432960 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9517913300 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/17/2008 | ||||||||
LastUpdateDate: | 01/31/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RUIZ | ||||||||
AuthorizedOfficialFirstName: | MARIEJOSE | ||||||||
AuthorizedOfficialMiddleName: | BALLEZA | ||||||||
AuthorizedOfficialTitleorPosition: | MENTAL HEALTH PEER SPECIALIST | ||||||||
AuthorizedOfficialTelephone: | 6198477051 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 171M00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator |   |
No ID Information.