Provider Demographics
NPI:1205001245
Name:DPH /SPECIAL PROGRAMS FOR YOUTH
Entity Type:Organization
Organization Name:DPH /SPECIAL PROGRAMS FOR YOUTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PIERRE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:415-753-7782
Mailing Address - Street 1:375 WOODSIDE AVE # 3
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94127-1221
Mailing Address - Country:US
Mailing Address - Phone:415-753-7784
Mailing Address - Fax:
Practice Address - Street 1:375 WOODSIDE AVE # 3
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94127-1221
Practice Address - Country:US
Practice Address - Phone:415-753-7784
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT23157305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service