Provider Demographics
NPI:1093418048
Name:MARY MAGDALENE COMMUNITY SERVICES AGENCY
Entity Type:Organization
Organization Name:MARY MAGDALENE COMMUNITY SERVICES AGENCY
Other - Org Name:MARY MAGDALENE COMMUNITY SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:GENEVA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-888-4519
Mailing Address - Street 1:620 N AURORA ST STE 7
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95202-2276
Mailing Address - Country:US
Mailing Address - Phone:209-888-4519
Mailing Address - Fax:
Practice Address - Street 1:620 N AURORA ST STE 7
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-2276
Practice Address - Country:US
Practice Address - Phone:209-888-4519
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-27
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No163WC0400XNursing Service ProvidersRegistered NurseCase ManagementGroup - Multi-Specialty