Provider Demographics
NPI:1609065523
Name:HUCKLEBERRY YOUTH PROGRAMS
Entity Type:Organization
Organization Name:HUCKLEBERRY YOUTH PROGRAMS
Other - Org Name:NINE GROVE LANE
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF PROGRAMS AND OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:
Authorized Official - Last Name:PRICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-668-2622
Mailing Address - Street 1:9 GROVE LN
Mailing Address - Street 2:
Mailing Address - City:SAN ANSELMO
Mailing Address - State:CA
Mailing Address - Zip Code:94960-2102
Mailing Address - Country:US
Mailing Address - Phone:415-453-5200
Mailing Address - Fax:415-453-8418
Practice Address - Street 1:9 GROVE LN
Practice Address - Street 2:
Practice Address - City:SAN ANSELMO
Practice Address - State:CA
Practice Address - Zip Code:94960-2102
Practice Address - Country:US
Practice Address - Phone:415-453-5200
Practice Address - Fax:415-453-8418
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HUCKLEBERRY YOUTH PROGRAMS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-16
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA210102876251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0000021A1CMedicaid