Basic Information
| Provider Information | |||||||||
| NPI: | 1467857615 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LINCOLN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1266 14TH ST | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946072205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102734700 | ||||||||
| FaxNumber: | 5105318083 | ||||||||
| Practice Location | |||||||||
| Address1: | 1050 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946062291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5105313111 | ||||||||
| FaxNumber: | 5105318083 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2014 | ||||||||
| LastUpdateDate: | 12/07/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BECWAR | ||||||||
| AuthorizedOfficialFirstName: | ALLISON | ||||||||
| AuthorizedOfficialMiddleName: | STAULCUP | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF PROGRAM OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5102734700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 0000054BM | 01 | MEDI-CAL PROVIDER NUMBER | OTHER |