Provider Demographics
NPI:1710329925
Name:SAN QUENTIN
Entity Type:Organization
Organization Name:SAN QUENTIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:ROACH
Authorized Official - Suffix:
Authorized Official - Credentials:PSYCH D
Authorized Official - Phone:415-454-1460
Mailing Address - Street 1:1635 JOSEPHINE ST
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94703-1320
Mailing Address - Country:US
Mailing Address - Phone:415-454-1469
Mailing Address - Fax:
Practice Address - Street 1:1635 JOSEPHINE ST
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94703-1320
Practice Address - Country:US
Practice Address - Phone:415-454-1469
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-29
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALCS14462OtherLCSW