Basic Information
Provider Information | |||||||||
NPI: | 1295249399 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CONTRA COSTA COUNTY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CONCORD SHELTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 50 DOUGLAS DR STE 310E | ||||||||
Address2: |   | ||||||||
City: | MARTINEZ | ||||||||
State: | CA | ||||||||
PostalCode: | 945534003 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9259575429 | ||||||||
FaxNumber: | 9259575401 | ||||||||
Practice Location | |||||||||
Address1: | 2047C ARNOLD INDUSTRIAL WAY | ||||||||
Address2: |   | ||||||||
City: | CONCORD | ||||||||
State: | CA | ||||||||
PostalCode: | 945205342 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9259575429 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/28/2017 | ||||||||
LastUpdateDate: | 11/28/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DECESARE | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: | H | ||||||||
AuthorizedOfficialTitleorPosition: | FISCAL MANAGER | ||||||||
AuthorizedOfficialTelephone: | 9259575429 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | CONTRA COSTA COUNTY | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.