Provider Demographics
NPI:1316024953
Name:CRESTWOOD BEHAVIORAL HEALTH, INC.
Entity Type:Organization
Organization Name:CRESTWOOD BEHAVIORAL HEALTH, INC.
Other - Org Name:CRESTWOOD C.E.N.T.E.R
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKBURN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-955-2322
Mailing Address - Street 1:7590 SHORELINE DR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-5455
Mailing Address - Country:US
Mailing Address - Phone:209-955-2328
Mailing Address - Fax:209-952-5314
Practice Address - Street 1:295 PINE BREEZE DR
Practice Address - Street 2:
Practice Address - City:ANGWIN
Practice Address - State:CA
Practice Address - Zip Code:94508-9620
Practice Address - Country:US
Practice Address - Phone:707-965-2461
Practice Address - Fax:707-965-2700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA02054010310500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness