Provider Demographics
NPI:1629468905
Name:CASA SERENA EATING DISORDERS PROGRAM
Entity Type:Organization
Organization Name:CASA SERENA EATING DISORDERS PROGRAM
Other - Org Name:JACQUELYN L HOLMES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:JACQUELYN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:MFT
Authorized Official - Phone:925-682-8252
Mailing Address - Street 1:1868 CLAYTON RD
Mailing Address - Street 2:SUITE 123
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-2547
Mailing Address - Country:US
Mailing Address - Phone:925-682-8252
Mailing Address - Fax:925-682-8313
Practice Address - Street 1:1868 CLAYTON RD
Practice Address - Street 2:SUITE 123
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-2547
Practice Address - Country:US
Practice Address - Phone:925-682-8252
Practice Address - Fax:925-682-8313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-26
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC25575106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty