Basic Information
| Provider Information | |||||||||
| NPI: | 1194811000 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MORONGO BASIN MENTAL HEALTH SERVICES ASSOC INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55475 SANTA FE TRL | ||||||||
| Address2: | |||||||||
| City: | YUCCA VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922843117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603653022 | ||||||||
| FaxNumber: | 7603653513 | ||||||||
| Practice Location | |||||||||
| Address1: | 55475 SANTA FE TRL | ||||||||
| Address2: | |||||||||
| City: | YUCCA VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922843117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603653022 | ||||||||
| FaxNumber: | 7603653513 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | RUSHBROOK | ||||||||
| AuthorizedOfficialFirstName: | SARAH | ||||||||
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| AuthorizedOfficialTitleorPosition: | CLINICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7603653022 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.