Provider Demographics
NPI:1265096838
Name:REDWOOD PSYCHOLOGICAL, INC
Entity type:Organization
Organization Name:REDWOOD PSYCHOLOGICAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:707-951-7620
Mailing Address - Street 1:1080 MASON MALL STE 6C
Mailing Address - Street 2:
Mailing Address - City:CRESCENT CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95531-4335
Mailing Address - Country:US
Mailing Address - Phone:707-951-7620
Mailing Address - Fax:
Practice Address - Street 1:1080 MASON MALL STE 6C
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95531-4335
Practice Address - Country:US
Practice Address - Phone:707-951-7620
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-29
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty