Basic Information
| Provider Information | |||||||||
| NPI: | 1558548792 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STRATEGIES FOR CHANGE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ESTRELLITA HIGH SCHOOL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4441 AUBURN BLVD | ||||||||
| Address2: | SUITE E | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958414139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164735764 | ||||||||
| FaxNumber: | 9164735766 | ||||||||
| Practice Location | |||||||||
| Address1: | 12935 MARENGO RD | ||||||||
| Address2: | |||||||||
| City: | GALT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956328422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164735764 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2008 | ||||||||
| LastUpdateDate: | 06/22/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KEETH | ||||||||
| AuthorizedOfficialFirstName: | CYNTHIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9164735764 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 340084AN | CA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 343425000 | 05 | CA | MEDICAID |