Provider Demographics
NPI:1790265023
Name:CHILDREN'S HOME OF STOCKTON
Entity Type:Organization
Organization Name:CHILDREN'S HOME OF STOCKTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HUMAN RESOURCES DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TICI
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:TRULY
Authorized Official - Suffix:
Authorized Official - Credentials:MDIV, DMIN, SHRM
Authorized Official - Phone:209-466-0853
Mailing Address - Street 1:430 N PILGRIM ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95205-4428
Mailing Address - Country:US
Mailing Address - Phone:209-466-0853
Mailing Address - Fax:209-466-6808
Practice Address - Street 1:430 N PILGRIM ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95205-4428
Practice Address - Country:US
Practice Address - Phone:209-466-0853
Practice Address - Fax:209-466-6808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390332238322D00000X
CA397002552322D00000X
CA397002553322D00000X
CA397002554322D00000X
CA390300131322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children