Basic Information
Provider Information
NPI: 1952950461
EntityType: 2
ReplacementNPI:  
OrganizationName: CITY OF BERKELEY
LastName:  
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Credential:  
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Mailing Information
Address1: 1521 UNIVERSITY AVE
Address2:  
City: BERKELEY
State: CA
PostalCode: 947031422
CountryCode: US
TelephoneNumber: 5109815280
FaxNumber:  
Practice Location
Address1: 1980 ALLSTON WAY STE H105
Address2:  
City: BERKELEY
State: CA
PostalCode: 947041463
CountryCode: US
TelephoneNumber: 5106446258
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/06/2019
LastUpdateDate: 09/19/2022
NPIDeactivationReasonCode:  
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ProviderGenderCode:  
AuthorizedOfficialLastName: BUELL
AuthorizedOfficialFirstName: JEFF
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: MENTAL HEALTH DIVISION MANAGER
AuthorizedOfficialTelephone: 5109815290
IsSoleProprietor:  
IsOrganizationSubpart: Y
ParentOrganizationLBN: CITY OF BERKELEY
AuthorizedOfficialNamePrefix:  
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AuthorizedOfficialCredential: LCSW
NPICertificationDate: 09/19/2022

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QM0801X  Y Ambulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)

No ID Information.


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