Basic Information
Provider Information | |||||||||
NPI: | 1336387455 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | REDWOOD COMMUNITY SERVICES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | THE HARBOR ON MAIN | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2077 | ||||||||
Address2: |   | ||||||||
City: | UKIAH | ||||||||
State: | CA | ||||||||
PostalCode: | 954822077 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7074672010 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 150 S MAIN ST | ||||||||
Address2: |   | ||||||||
City: | LAKEPORT | ||||||||
State: | CA | ||||||||
PostalCode: | 954535017 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7079945486 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/27/2009 | ||||||||
LastUpdateDate: | 02/12/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KELLY | ||||||||
AuthorizedOfficialFirstName: | VICTORIA | ||||||||
AuthorizedOfficialMiddleName: | JERUSHA | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 7074672010 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | REDWOOD COMMUNITY SERVICES, INC. | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LMFT | ||||||||
NPICertificationDate: | 02/12/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator |   | 171W00000X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Contractor |   | 101Y00000X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor |   | 1041C0700X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   | 251B00000X |   |   | N |   | Agencies | Case Management |   | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 17CC | 01 | CA | LAKE CO MH SITE # | OTHER |