Provider Demographics
NPI:1972658128
Name:COUNTY OF MENDOCINO
Entity Type:Organization
Organization Name:COUNTY OF MENDOCINO
Other - Org Name:BEHAVIORAL HEALTH & RECOVERY SERVICES - MENTAL HEALTH
Other - Org Type:Other Name
Authorized Official - Title/Position:BHRS DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JENINE
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:707-472-2341
Mailing Address - Street 1:1120 S DORA ST
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-6340
Mailing Address - Country:US
Mailing Address - Phone:707-472-2300
Mailing Address - Fax:
Practice Address - Street 1:1120 S DORA ST
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-3919
Practice Address - Country:US
Practice Address - Phone:707-463-4303
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF MENDOCINO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-25
Last Update Date:2023-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00023OtherMH COUNTY MEDICAL INDENTI
CABBB33295BOtherMH SUBMITTER NUMBER
CA2315OtherMEDICAL PROVIDER #
CA2315Medicaid
CA2315OtherMEDICAL PROVIDER #