Provider Demographics
NPI:1679864185
Name:KIDANGO
Entity Type:Organization
Organization Name:KIDANGO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH CLINICIAN
Authorized Official - Prefix:MISS
Authorized Official - First Name:LILIAN
Authorized Official - Middle Name:PATRICIA
Authorized Official - Last Name:ZELAYA
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:707-921-9232
Mailing Address - Street 1:44000 OLD WARM SPRINGS BLVD
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-6145
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:44000 OLD WARM SPRINGS BLVD
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-6145
Practice Address - Country:US
Practice Address - Phone:510-897-6900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-02
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30172251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA30172OtherBOARD OF BEHAVIORAL SCIENCES