Provider Demographics
NPI:1013424522
Name:RIVERSIDE UNVERSITY BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:RIVERSIDE UNVERSITY BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:MR
Authorized Official - First Name:THADDEUS
Authorized Official - Middle Name:A
Authorized Official - Last Name:WICKI
Authorized Official - Suffix:
Authorized Official - Credentials:MFT
Authorized Official - Phone:951-443-2200
Mailing Address - Street 1:1688 N PERRIS BLVD STE L6-11
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92571-4709
Mailing Address - Country:US
Mailing Address - Phone:951-443-2200
Mailing Address - Fax:
Practice Address - Street 1:1688 N PERRIS BLVD STE L6-11
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571-4709
Practice Address - Country:US
Practice Address - Phone:951-443-2200
Practice Address - Fax:951-443-2230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-05
Last Update Date:2018-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA101YM0800XMedicaid