Provider Demographics
NPI:1841787009
Name:COUNTY OF MARIN
Entity Type:Organization
Organization Name:COUNTY OF MARIN
Other - Org Name:BHRS IMPACT PROGRAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COMPLIANCE/PRIVACY OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ROSANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:LALLANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-473-2087
Mailing Address - Street 1:20 N SAN PEDRO RD STE 2021
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-4158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1682 NOVATO BLVD STE 105
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94947-7021
Practice Address - Country:US
Practice Address - Phone:415-473-2721
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF MARIN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-04-13
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2177Medicaid