Basic Information
| Provider Information | |||||||||
| NPI: | 1700367166 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LINCOLN | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | HOPE CC CARMEN DRAGON ELEMENTARY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1266 14TH ST | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946072205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102734700 | ||||||||
| FaxNumber: | 5105308083 | ||||||||
| Practice Location | |||||||||
| Address1: | 4721 VISTA GRANDE DR | ||||||||
| Address2: | |||||||||
| City: | ANTIOCH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945318619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9257797475 | ||||||||
| FaxNumber: | 9257797476 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2018 | ||||||||
| LastUpdateDate: | 08/23/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MONROY-ABURTO | ||||||||
| AuthorizedOfficialFirstName: | CATALINA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | QA SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 5102734700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.