Provider Demographics
NPI:1619039211
Name:COUNTY OF LAKE
Entity Type:Organization
Organization Name:COUNTY OF LAKE
Other - Org Name:LAKE COUNTY BEHAVIORAL HEALTH SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:BEHAVIORAL HEALTH DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ELISE
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:707-274-9101
Mailing Address - Street 1:P O BOX 1024
Mailing Address - Street 2:
Mailing Address - City:LUCERNE
Mailing Address - State:CA
Mailing Address - Zip Code:95458
Mailing Address - Country:US
Mailing Address - Phone:707-274-9101
Mailing Address - Fax:707-274-9192
Practice Address - Street 1:7000B S CENTER DR
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-8131
Practice Address - Country:US
Practice Address - Phone:707-994-7090
Practice Address - Fax:707-994-7092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251S00000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA171712Medicaid