Basic Information
| Provider Information | |||||||||
| NPI: | 1396858668 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTY OF MODOC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | BEHAVIORAL HEALTH SERVICES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 441 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ALTURAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961013457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302336312 | ||||||||
| FaxNumber: | 5302336339 | ||||||||
| Practice Location | |||||||||
| Address1: | 441 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ALTURAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961013457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302336312 | ||||||||
| FaxNumber: | 5302336339 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 08/14/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STOCKTON | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, HEALTH SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 5302336312 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COUNTY OF MODOC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PH. D, MSW, BSN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.