Basic Information
| Provider Information | |||||||||
| NPI: | 1750415113 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CITY OF BERKELEY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | FAMILY YOUTH AND CHILDREN | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2180 MILVIA ST. | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947041122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5109815270 | ||||||||
| FaxNumber: | 5109815235 | ||||||||
| Practice Location | |||||||||
| Address1: | 1521 UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947031422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5109815280 | ||||||||
| FaxNumber: | 5109815255 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2007 | ||||||||
| LastUpdateDate: | 10/07/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GROLNIC-MCCLURG | ||||||||
| AuthorizedOfficialFirstName: | STEVE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER OF MENTAL HEALTH | ||||||||
| AuthorizedOfficialTelephone: | 5109815280 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
No ID Information.