Provider Demographics
NPI:1326536632
Name:FIRST BAPTIST CHURCH OF LODI
Entity Type:Organization
Organization Name:FIRST BAPTIST CHURCH OF LODI
Other - Org Name:ONE-EIGHTY ADOLESCENT & FAMILY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXEC DIR ONE-EIGHTY YOUTH PROGRAMS
Authorized Official - Prefix:
Authorized Official - First Name:ALISON
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGREGOR
Authorized Official - Suffix:
Authorized Official - Credentials:MFT
Authorized Official - Phone:209-339-1616
Mailing Address - Street 1:17 W LOCKEFORD ST
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-2125
Mailing Address - Country:US
Mailing Address - Phone:209-339-1616
Mailing Address - Fax:
Practice Address - Street 1:17 W LOCKEFORD ST
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-2125
Practice Address - Country:US
Practice Address - Phone:209-339-1616
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FIRST BAPTIST CHURCH OF LODI
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-04-23
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1425101YS0200X
CA101549106H00000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchoolGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty