Provider Demographics
NPI:1902010887
Name:COUNTY OF SAN BERNARDINO
Entity Type:Organization
Organization Name:COUNTY OF SAN BERNARDINO
Other - Org Name:DAAS AGE WISE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MENTAL HEALTH CLINIC SUPERVISOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:951-662-3730
Mailing Address - Street 1:18818 HWY 18
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-0009
Mailing Address - Country:US
Mailing Address - Phone:760-995-8813
Mailing Address - Fax:760-995-8929
Practice Address - Street 1:18818 HWY 18
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-0009
Practice Address - Country:US
Practice Address - Phone:760-995-8813
Practice Address - Fax:760-995-8929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAZZZ74743Z261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA36DMMedicaid