Provider Demographics
NPI:1659634814
Name:UNITED CEREBRAL PALSY OF SAN JOAQUIN, CALAVERAS, AMADOR INC
Entity Type:Organization
Organization Name:UNITED CEREBRAL PALSY OF SAN JOAQUIN, CALAVERAS, AMADOR INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL & FAMILY SERVICES DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LINK
Authorized Official - Suffix:
Authorized Official - Credentials:BS OF OT
Authorized Official - Phone:209-751-3013
Mailing Address - Street 1:333 W BEN HOLT DR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-3906
Mailing Address - Country:US
Mailing Address - Phone:209-751-3106
Mailing Address - Fax:209-751-3125
Practice Address - Street 1:333 W BEN HOLT DR
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-3906
Practice Address - Country:US
Practice Address - Phone:209-751-3106
Practice Address - Fax:209-751-3125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251C00000X, 252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No252Y00000XAgenciesEarly Intervention Provider Agency