Basic Information
| Provider Information | |||||||||
| NPI: | 1891859047 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | REDWOOD COMMUNITY SERVICES, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RCS BEHAVIORAL HEALTH SERVICES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2077 | ||||||||
| Address2: | 631 S. ORCHARD STREET | ||||||||
| City: | UKIAH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954822077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074672010 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 160 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LAKEPORT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072630372 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2006 | ||||||||
| LastUpdateDate: | 01/13/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KELLY | ||||||||
| AuthorizedOfficialFirstName: | VICTORIA | ||||||||
| AuthorizedOfficialMiddleName: | JERUSHA | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7074672010 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | 01/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 171M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator | 171W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Contractor | 251B00000X | N | Agencies | Case Management | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 01164707 | 05 | CA | MEDICAID | 49EC1 | 01 | CA | SONOMA CO PROVIDER NO | OTHER | 01816207 | 05 | CA | MEDICAID | 5878 | 01 | CA | SUTTER-YUBA CO PROVIDER NO | OTHER | 1791 | 01 | CA | LAKE CO. MH SITE # | OTHER | 0851 | 01 | CA | DEL NORTE CO PROVIDER NO | OTHER | 27A7 | 01 | CA | NAPA CO SITE # | OTHER | 01726307 | 05 | CA | MEDICAID | 2377 | 01 | MENDOCINO CO. PROVIDER NO. | OTHER |