Provider Demographics
NPI:1710249461
Name:DEPATMENT OF BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:DEPATMENT OF BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHIATRIC TECHNICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:BRIDGET
Authorized Official - Last Name:OLSEN
Authorized Official - Suffix:
Authorized Official - Credentials:LPT
Authorized Official - Phone:909-598-6462
Mailing Address - Street 1:1300 E COOLEY DR
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-3905
Mailing Address - Country:US
Mailing Address - Phone:909-423-0750
Mailing Address - Fax:
Practice Address - Street 1:1300 E COOLEY DR
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-3905
Practice Address - Country:US
Practice Address - Phone:909-423-0750
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-08
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32634284300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes284300000XHospitalsSpecial Hospital