Provider Demographics
NPI:1619155942
Name:SAN MATEO COUNTY
Entity Type:Organization
Organization Name:SAN MATEO COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GROUP HOME COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-694-0353
Mailing Address - Street 1:400 EDMONDS RD
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94062-3803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 EDMONDS RD
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94062-3803
Practice Address - Country:US
Practice Address - Phone:650-839-1810
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CANYON OAKS YOUTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-08
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness