Provider Demographics
NPI:1194853713
Name:COUNTY OF MENDOCINO
Entity Type:Organization
Organization Name:COUNTY OF MENDOCINO
Other - Org Name:BEHAVIORAL HEALTH & RECOVERY SERVICES - MENTAL HEALTH
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JENINE
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:707-472-2355
Mailing Address - Street 1:1120 S DORA ST
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482
Mailing Address - Country:US
Mailing Address - Phone:707-467-2300
Mailing Address - Fax:
Practice Address - Street 1:790 S FRANKLIN ST STE B
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437-5456
Practice Address - Country:US
Practice Address - Phone:707-964-4747
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF MENDOCINO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-02
Last Update Date:2023-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABBB33295BOtherMH SUBMITTER #
CA00023Medicaid
CA2311Medicaid
CA156456Medicare ID - Type UnspecifiedMH MEDICARE RECEIVER
CABBB33295BOtherMH SUBMITTER #