Basic Information
| Provider Information | |||||||||
| NPI: | 1417074089 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARIPOSA COUNTY BEHAVIORAL HEALTH & RECOVERY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MARIPOSA COUNTY FOSTER CARE ASO | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 99 | ||||||||
| Address2: | |||||||||
| City: | MARIPOSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953380099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2099662000 | ||||||||
| FaxNumber: | 2099668251 | ||||||||
| Practice Location | |||||||||
| Address1: | 5362 LEMEE LANE | ||||||||
| Address2: | |||||||||
| City: | MARIPOSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953380099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2099662000 | ||||||||
| FaxNumber: | 2099668251 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2007 | ||||||||
| LastUpdateDate: | 04/20/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MORTON | ||||||||
| AuthorizedOfficialFirstName: | HOPE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | ACCOUNT CLERK III | ||||||||
| AuthorizedOfficialTelephone: | 2099662000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MARIPOSA COUNTY BEHAVIORAL HEALTH & RECOVERY SERVICES | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.