Provider Demographics
NPI:1043265044
Name:STATE HEALTH CARE DUAL DIAGNOSIS
Entity Type:Organization
Organization Name:STATE HEALTH CARE DUAL DIAGNOSIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:EDNA
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-628-9512
Mailing Address - Street 1:19300 RINALDI ST
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91326-1651
Mailing Address - Country:US
Mailing Address - Phone:310-628-9512
Mailing Address - Fax:818-392-5025
Practice Address - Street 1:4042 S DEMAREE ST
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93277-9476
Practice Address - Country:US
Practice Address - Phone:310-628-9512
Practice Address - Fax:818-392-5025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty