Basic Information
| Provider Information | |||||||||
| NPI: | 1629496187 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SCMHTC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2150 STOCKTON BLVD | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958171337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9168751000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2150 STOCKTON BLVD | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958171337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9168751000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2014 | ||||||||
| LastUpdateDate: | 04/02/2014 | ||||||||
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| AuthorizedOfficialLastName: | BRAY | ||||||||
| AuthorizedOfficialFirstName: | CARL | ||||||||
| AuthorizedOfficialMiddleName: | SCOTT | ||||||||
| AuthorizedOfficialTitleorPosition: | TREATMENT CENTER PROGRAM COORDINATO | ||||||||
| AuthorizedOfficialTelephone: | 9168751020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MFT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 323P00000X | Y | Residential Treatment Facilities | Psychiatric Residential Treatment Facility |
No ID Information.