Provider Demographics
NPI:1427219237
Name:COUNTY OF SISKIYOU BEHAVIORAL HEALTH SERVICES - 00047
Entity Type:Organization
Organization Name:COUNTY OF SISKIYOU BEHAVIORAL HEALTH SERVICES - 00047
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE SERVICES MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-841-4732
Mailing Address - Street 1:1107 REAM AVE
Mailing Address - Street 2:
Mailing Address - City:MT. SHASTA
Mailing Address - State:CA
Mailing Address - Zip Code:96067
Mailing Address - Country:US
Mailing Address - Phone:530-918-7200
Mailing Address - Fax:530-918-7216
Practice Address - Street 1:1107 REAM AVE
Practice Address - Street 2:
Practice Address - City:MOUNT SHASTA
Practice Address - State:CA
Practice Address - Zip Code:96067-9768
Practice Address - Country:US
Practice Address - Phone:530-918-7200
Practice Address - Fax:530-918-7216
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF SISKIYOU BEHAVIORAL HEALTH SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-24
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA01114108Medicaid