Provider Demographics
NPI:1629128079
Name:EXCEL ACADEMY SHASTA COUNTY MENTAL HEALTH
Entity Type:Organization
Organization Name:EXCEL ACADEMY SHASTA COUNTY MENTAL HEALTH
Other - Org Name:EXCEL ACADEMY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF MENTAL HEALTH
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:530-225-5200
Mailing Address - Street 1:PO BOX 496048
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96049-6048
Mailing Address - Country:US
Mailing Address - Phone:530-225-5200
Mailing Address - Fax:530-225-5977
Practice Address - Street 1:3711 OASIS RD
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96003-0397
Practice Address - Country:US
Practice Address - Phone:530-225-5200
Practice Address - Fax:530-225-5977
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF SHASTA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-10
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4578Medicaid