Provider Demographics
NPI:1619734662
Name:REDWOOD BEHAVIORAL HEALTH A PROFESSIONAL NURSING CORPORATION
Entity Type:Organization
Organization Name:REDWOOD BEHAVIORAL HEALTH A PROFESSIONAL NURSING CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THERESA CARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-445-5414
Mailing Address - Street 1:7250 REDWOOD BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94945-3269
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7250 REDWOOD BLVD STE 300
Practice Address - Street 2:OFFICE 349
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94945-3269
Practice Address - Country:US
Practice Address - Phone:415-878-3722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-05
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty