Provider Demographics
NPI:1477846012
Name:CRESTWOOD BEHAVIORAL HEALTH, INC.
Entity Type:Organization
Organization Name:CRESTWOOD BEHAVIORAL HEALTH, INC.
Other - Org Name:DREAM HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MRS
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:209-444-9774
Practice Address - Street 1:4256 FRUITRIDGE RD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95820-5047
Practice Address - Country:US
Practice Address - Phone:209-427-2363
Practice Address - Fax:916-429-2631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-16
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness