Provider Demographics
NPI: | 1083266886 |
---|---|
Name: | HUMBOLDT COUNTY BEHAVIORAL HEALTH |
Entity Type: | Organization |
Organization Name: | HUMBOLDT COUNTY BEHAVIORAL HEALTH |
Other - Org Name: | MOBILE AND REGIONAL SERVICES |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | BH DIRECTOR |
Authorized Official - Prefix: | |
Authorized Official - First Name: | EMI |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | BOTZLER-ROGERS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | LMFT |
Authorized Official - Phone: | 707-268-2990 |
Mailing Address - Street 1: | 720 WOOD ST |
Mailing Address - Street 2: | |
Mailing Address - City: | EUREKA |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 95501-4413 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 707-268-2990 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 2944 D ST |
Practice Address - Street 2: | |
Practice Address - City: | EUREKA |
Practice Address - State: | CA |
Practice Address - Zip Code: | 95501-4349 |
Practice Address - Country: | US |
Practice Address - Phone: | 707-268-2990 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2019-07-11 |
Last Update Date: | 2020-07-16 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 251S00000X | Agencies | Community/Behavioral Health |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CA | 000001203 | Medicaid |