Basic Information
| Provider Information | |||||||||
| NPI: | 1518418482 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REDWOOD COMMUNITY SERVICES, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2077 | ||||||||
| Address2: | |||||||||
| City: | UKIAH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954822077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074672010 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9981B SPRING VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | POTTER VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954699713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7077431015 | ||||||||
| FaxNumber: | 7077431018 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2016 | ||||||||
| LastUpdateDate: | 08/05/2020 | ||||||||
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| AuthorizedOfficialLastName: | KELLY | ||||||||
| AuthorizedOfficialFirstName: | VICTORIA | ||||||||
| AuthorizedOfficialMiddleName: | JERUSHA | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7074672010 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | REDWOOD COMMUNITY SERVICES, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | 08/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 251B00000X | N | Agencies | Case Management | 251S00000X | N | Agencies | Community/Behavioral Health | 322D00000X | Y | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |
No ID Information.