Basic Information
| Provider Information | |||||||||
| NPI: | 1215963699 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CITY OF BERKELEY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3282 ADELINE STREET | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5109815280 | ||||||||
| FaxNumber: | 5105969299 | ||||||||
| Practice Location | |||||||||
| Address1: | 2640 MARTIN LUTHER KING JR WAY | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947043238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5109815290 | ||||||||
| FaxNumber: | 5109815265 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2006 | ||||||||
| LastUpdateDate: | 03/05/2020 | ||||||||
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| AuthorizedOfficialLastName: | GROLNIC-MCCLURG | ||||||||
| AuthorizedOfficialFirstName: | STEVE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER OF MENTAL HEALTH | ||||||||
| AuthorizedOfficialTelephone: | 5109815280 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | 03/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.