Basic Information
| Provider Information | |||||||||
| NPI: | 1912926692 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAN MATEO COUNTY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SOUTH COUNTY MENTAL HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 802 BREWSTER AVE | ||||||||
| Address2: | |||||||||
| City: | REDWOOD CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940631510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6503634111 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 802 BREWSTER AVE | ||||||||
| Address2: | |||||||||
| City: | REDWOOD CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940631510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6503634111 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 09/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MANCINI | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BHRS INTERIM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6505732748 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SAN MATEO COUNTY | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.