Provider Demographics
NPI:1417070699
Name:EDC MH
Entity Type:Organization
Organization Name:EDC MH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MSW II INTERN
Authorized Official - Prefix:MRS
Authorized Official - First Name:VIBHA
Authorized Official - Middle Name:K
Authorized Official - Last Name:UDUPA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-564-0503
Mailing Address - Street 1:126 REDWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95815-2010
Mailing Address - Country:US
Mailing Address - Phone:916-564-0503
Mailing Address - Fax:
Practice Address - Street 1:126 REDWOOD AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95815-2010
Practice Address - Country:US
Practice Address - Phone:916-564-0503
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3714251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health