Basic Information
Provider Information | |||||||||
NPI: | 1578699260 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | REDWOOD COMMUNITY ACTION AGENCY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | YOUTH SERVICES BUREAU | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 904 G ST | ||||||||
Address2: |   | ||||||||
City: | EUREKA | ||||||||
State: | CA | ||||||||
PostalCode: | 95501 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7072692001 | ||||||||
FaxNumber: | 7074450884 | ||||||||
Practice Location | |||||||||
Address1: | 1100 CALIFORNIA STREET | ||||||||
Address2: |   | ||||||||
City: | EUREKA | ||||||||
State: | CA | ||||||||
PostalCode: | 95501 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7074438322 | ||||||||
FaxNumber: | 7074451445 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/26/2007 | ||||||||
LastUpdateDate: | 04/23/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WILD | ||||||||
AuthorizedOfficialFirstName: | RACHEL | ||||||||
AuthorizedOfficialMiddleName: | IRENE | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE COORDINATOR II | ||||||||
AuthorizedOfficialTelephone: | 7072692003 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/23/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106H00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   | 171M00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator |   |
No ID Information.