Provider Demographics
NPI:1568604452
Name:MENTAL HEALTH SUBSTANCE ABUSE PROGRAM
Entity Type:Organization
Organization Name:MENTAL HEALTH SUBSTANCE ABUSE PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BEHAVIORAL HEALTH SPECIALIST III
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARYJO
Authorized Official - Middle Name:
Authorized Official - Last Name:LOERA
Authorized Official - Suffix:
Authorized Official - Credentials:CCBADC/CAADAC
Authorized Official - Phone:760-347-0754
Mailing Address - Street 1:83912 AVENUE 45 STE 9
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-3338
Mailing Address - Country:US
Mailing Address - Phone:760-347-0754
Mailing Address - Fax:760-347-8507
Practice Address - Street 1:83912 AVENUE 45 STE 9
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-3338
Practice Address - Country:US
Practice Address - Phone:760-347-0754
Practice Address - Fax:760-347-8507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-24
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARW2331251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health