Basic Information
Provider Information | |||||||||
NPI: | 1881692390 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COUNTY OF SHASTA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SHASTA COUNTY MENTAL HEALTH | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 496048 | ||||||||
Address2: |   | ||||||||
City: | REDDING | ||||||||
State: | CA | ||||||||
PostalCode: | 960496048 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5302255200 | ||||||||
FaxNumber: | 5302255977 | ||||||||
Practice Location | |||||||||
Address1: | 2640 BRESLAUER WAY | ||||||||
Address2: |   | ||||||||
City: | REDDING | ||||||||
State: | CA | ||||||||
PostalCode: | 960014246 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5302255200 | ||||||||
FaxNumber: | 5302255977 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/08/2005 | ||||||||
LastUpdateDate: | 07/05/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BURCH | ||||||||
AuthorizedOfficialFirstName: | LAURA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF MENTAL HEALTH | ||||||||
AuthorizedOfficialTelephone: | 5302456269 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | COUNTY OF SHASTA | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/05/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | N |   | Agencies | Community/Behavioral Health |   | 261QM0801X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
ID | Type | State | Issuer | Description | 4581 | 05 | CA |   | MEDICAID | 4515 | 05 | CA |   | MEDICAID | ZZZ85235Z | 01 | CA | BLUE SHIELD CALIFORNIA | OTHER | 4578 | 05 | CA |   | MEDICAID | 4579 | 05 | CA |   | MEDICAID | 4580 | 05 | CA |   | MEDICAID |