Basic Information
Provider Information | |||||||||
NPI: | 1427401439 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | REDWOOD COMMUNITY SERVICES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | RCS - CRISIS | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2077 | ||||||||
Address2: | 631 ORCHARD STREET | ||||||||
City: | UKIAH | ||||||||
State: | CA | ||||||||
PostalCode: | 954822077 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7074672010 | ||||||||
FaxNumber: | 7074626994 | ||||||||
Practice Location | |||||||||
Address1: | 780 S DORA ST | ||||||||
Address2: |   | ||||||||
City: | UKIAH | ||||||||
State: | CA | ||||||||
PostalCode: | 954825348 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7074679065 | ||||||||
FaxNumber: | 7074671110 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/14/2016 | ||||||||
LastUpdateDate: | 01/21/2020 | ||||||||
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: | LCSW | ||||||||
NPICertificationDate: | 01/21/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X |   |   | N |   | Agencies | Case Management |   | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 23C2 | 01 | CA | MENDOCINO COUNTY SMPH SITE CERT | OTHER |