Basic Information
| Provider Information | |||||||||
| NPI: | 1790054856 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | REDWOOD COMMUNITY SERVICES, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | RCS BEHAVIORAL HEALTH SERVICES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 422 | ||||||||
| Address2: | 780 S. DORA ST. | ||||||||
| City: | UKIAH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954820422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074672010 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 32670 HIGHWAY 20 UNIT 2 | ||||||||
| Address2: | |||||||||
| City: | FORT BRAGG | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954375708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7079641136 | ||||||||
| FaxNumber: | 7079644558 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2011 | ||||||||
| LastUpdateDate: | 01/21/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KELLY | ||||||||
| AuthorizedOfficialFirstName: | VICTORIA | ||||||||
| AuthorizedOfficialMiddleName: | JERUSHA | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFCIER | ||||||||
| AuthorizedOfficialTelephone: | 7074672010 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | REDWOOD COMMUNITY SERVICES, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | 01/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | N | Agencies | Case Management | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 23CJ | 01 | CA | MENDOCINO COUNTY PROVIDER NUMBER | OTHER | 67958 | 01 | CA | CITY OF FORT BRAGG - BUISNESS LICENSE | OTHER |