Basic Information
| Provider Information | |||||||||
| NPI: | 1669773743 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LINCOLN | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1266 14TH ST | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946072205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102734700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1266 14TH ST | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946072205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5105313111 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2010 | ||||||||
| LastUpdateDate: | 12/07/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BECWAR | ||||||||
| AuthorizedOfficialFirstName: | ALLISON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR DIRECTOR OF SBS | ||||||||
| AuthorizedOfficialTelephone: | 5108670944 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 0000054BM | 01 | CA | MEDI-CAL PROVIDER NUMBER | OTHER |