Provider Demographics
NPI:1376623256
Name:CRESTWOOD BEHAVIORAL HEALTH, INC
Entity Type:Organization
Organization Name:CRESTWOOD BEHAVIORAL HEALTH, INC
Other - Org Name:CRESTWOOD BEHAVIORAL HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CAO/TREASURER
Authorized Official - Prefix:MS
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 1:1425 FRUITDALE AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-3234
Practice Address - Country:US
Practice Address - Phone:408-275-1010
Practice Address - Fax:408-275-1066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness