Basic Information
| Provider Information | |||||||||
| NPI: | 1538445358 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | REDWOOD COMMUNITY SERVICES, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MADRONE HOUSE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2077 | ||||||||
| Address2: | |||||||||
| City: | UKIAH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954822077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074672010 | ||||||||
| FaxNumber: | 7074672009 | ||||||||
| Practice Location | |||||||||
| Address1: | 7351 SEMS LN | ||||||||
| Address2: | |||||||||
| City: | REDWOOD VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074679192 | ||||||||
| FaxNumber: | 7074679345 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2011 | ||||||||
| LastUpdateDate: | 01/21/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KELLY | ||||||||
| AuthorizedOfficialFirstName: | VICTORIA | ||||||||
| AuthorizedOfficialMiddleName: | JERSUHA | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7074672010 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | 01/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | N | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness | 251S00000X | CA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 23CI | 01 | CA | MENDOCINO COUNTY PROVIDER NUMBER | OTHER |