Provider Demographics
NPI:1467823674
Name:SAINT JOHN'S PROGRAM FOR REAL CHANGE
Entity Type:Organization
Organization Name:SAINT JOHN'S PROGRAM FOR REAL CHANGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF PROGRAM OFFICER-INTEG. HEALTH
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BARRON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYCHOLOGIST
Authorized Official - Phone:916-453-1482
Mailing Address - Street 1:2443 FAIR OAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-7684
Mailing Address - Country:US
Mailing Address - Phone:916-453-1482
Mailing Address - Fax:
Practice Address - Street 1:8401 JACKSON RD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95826-3904
Practice Address - Country:US
Practice Address - Phone:916-453-1482
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-14
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 24140251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health