Basic Information
| Provider Information | |||||||||
| NPI: | 1831237015 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | REDWOOD COMMUNITY SERVICES, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2077 | ||||||||
| Address2: | 631 S. ORCHARD ST. | ||||||||
| City: | UKIAH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954822077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074672010 | ||||||||
| FaxNumber: | 7074626994 | ||||||||
| Practice Location | |||||||||
| Address1: | 631 S ORCHARD AVE | ||||||||
| Address2: | |||||||||
| City: | UKIAH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954825011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074722922 | ||||||||
| FaxNumber: | 7074625172 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2007 | ||||||||
| LastUpdateDate: | 01/21/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KELLY | ||||||||
| AuthorizedOfficialFirstName: | VICTORIA | ||||||||
| AuthorizedOfficialMiddleName: | JERUSHA | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7074672010 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | 01/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103TR0400X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Rehabilitation | 1041C0700X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 171M00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator | 171W00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Contractor | 251300000X | N | Agencies | Local Education Agency (LEA) | 251B00000X | N | Agencies | Case Management | 252Y00000X | N | Agencies | Early Intervention Provider Agency | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 01418707 | 05 | CA | MEDICAID | 01863308 | 05 | CA | MEDICAID | 12AA | 01 | CA | HUMBOLDT CO PROVIDER NO | OTHER | 2392 | 01 | CA | MENDOCINO CO MH SITE # | OTHER | 49EE1 | 01 | CA | SONOMA CO PROVIDER NO | OTHER |