Provider Demographics
NPI:1710298880
Name:HUCKLEBERRY YOUTH PROGRAMS
Entity Type:Organization
Organization Name:HUCKLEBERRY YOUTH PROGRAMS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:QUIGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-258-4944
Mailing Address - Street 1:361 3RD STREET
Mailing Address - Street 2:SUITE G
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901
Mailing Address - Country:US
Mailing Address - Phone:415-258-4944
Mailing Address - Fax:
Practice Address - Street 1:361 3RD STREET
Practice Address - Street 2:SUITE G
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901
Practice Address - Country:US
Practice Address - Phone:415-258-4944
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-23
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health