Provider Demographics
NPI:1043434095
Name:PACIFIC CENTER FOR HUMAN GROWTH
Entity Type:Organization
Organization Name:PACIFIC CENTER FOR HUMAN GROWTH
Other - Org Name:PACIFIC CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LASARA
Authorized Official - Middle Name:FIREFOX
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-293-5153
Mailing Address - Street 1:2130 CENTER ST STE 200
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94704-1386
Mailing Address - Country:US
Mailing Address - Phone:510-992-6207
Mailing Address - Fax:510-548-2938
Practice Address - Street 1:2130 CENTER ST STE 200
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-1386
Practice Address - Country:US
Practice Address - Phone:510-992-6207
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC32439261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)