Provider Demographics
NPI:1376972190
Name:BLUE HERON
Entity Type:Organization
Organization Name:BLUE HERON
Other - Org Name:KONOCTI UNIFIED
Other - Org Type:Other Name
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:BECNEL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:707-994-6475
Mailing Address - Street 1:15850 DAM ROAD EXT
Mailing Address - Street 2:
Mailing Address - City:CLEARLAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95422-9359
Mailing Address - Country:US
Mailing Address - Phone:707-994-6447
Mailing Address - Fax:
Practice Address - Street 1:15850 DAM ROAD EXT
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-9359
Practice Address - Country:US
Practice Address - Phone:707-994-6447
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-02
Last Update Date:2013-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)