Provider Demographics
NPI:1336387455
Name:REDWOOD COMMUNITY SERVICES, INC.
Entity Type:Organization
Organization Name:REDWOOD COMMUNITY SERVICES, INC.
Other - Org Name:THE HARBOR ON MAIN
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:JERUSHA
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:707-467-2010
Mailing Address - Street 1:PO BOX 2077
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-2077
Mailing Address - Country:US
Mailing Address - Phone:707-467-2010
Mailing Address - Fax:
Practice Address - Street 1:150 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-5017
Practice Address - Country:US
Practice Address - Phone:707-994-5486
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REDWOOD COMMUNITY SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-27
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
No171W00000XOther Service ProvidersContractorGroup - Single Specialty
No251B00000XAgenciesCase ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA17CCOtherLAKE CO MH SITE #