Basic Information
Provider Information | |||||||||
NPI: | 1811419658 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COUNTY OF SHASTA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HHSA CHILDREN'S SERVICES, MH, 1580 MARKET ST | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2640 BRESLAUER WAY | ||||||||
Address2: |   | ||||||||
City: | REDDING | ||||||||
State: | CA | ||||||||
PostalCode: | 960014246 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5302255200 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1580 MARKET ST | ||||||||
Address2: |   | ||||||||
City: | REDDING | ||||||||
State: | CA | ||||||||
PostalCode: | 960011023 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5302255200 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/13/2017 | ||||||||
LastUpdateDate: | 07/13/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | EWERT | ||||||||
AuthorizedOfficialFirstName: | DONNELL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF MENTAL HEALTH | ||||||||
AuthorizedOfficialTelephone: | 5302456750 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | COUNTY OF SHASTA | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MPH | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
No ID Information.