Basic Information
| Provider Information | |||||||||
| NPI: | 1265772198 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CSP-CORCORAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4001 KING AVE | ||||||||
| Address2: | |||||||||
| City: | CORCORAN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932129611 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4001 KING AVE | ||||||||
| Address2: | |||||||||
| City: | CORCORAN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932129611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5599928800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2013 | ||||||||
| LastUpdateDate: | 03/01/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GONZALES | ||||||||
| AuthorizedOfficialFirstName: | JESSE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR SUPEVISOR (ACTING) | ||||||||
| AuthorizedOfficialTelephone: | 5599928800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | EDD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | PSY21977 | CA | Y | Agencies | Case Management |
No ID Information.