Provider Demographics
NPI:1609096817
Name:KEYSTONE SCHOOL ELMIRA
Entity Type:Organization
Organization Name:KEYSTONE SCHOOL ELMIRA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:MS
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCARTHY
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:707-453-6227
Mailing Address - Street 1:PO BOX 525
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:CA
Mailing Address - Zip Code:95625-0525
Mailing Address - Country:US
Mailing Address - Phone:707-453-6227
Mailing Address - Fax:707-453-6957
Practice Address - Street 1:5416 HOLDENER ROAD
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:CA
Practice Address - Zip Code:95625
Practice Address - Country:US
Practice Address - Phone:707-453-6227
Practice Address - Fax:707-453-6957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48705736204887251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA251S00000XMedicaid