Provider Demographics
NPI:1356798383
Name:CHILDRENS CRISIS INTERVENTION PROGRAM
Entity type:Organization
Organization Name:CHILDRENS CRISIS INTERVENTION PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:VERNON
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-866-4080
Mailing Address - Street 1:400 OYSTER POINT BLVD
Mailing Address - Street 2:SUITE 501
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94080-1904
Mailing Address - Country:US
Mailing Address - Phone:650-866-4080
Mailing Address - Fax:650-866-4081
Practice Address - Street 1:1540 FLORIDA AVE STE 212
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4430
Practice Address - Country:US
Practice Address - Phone:209-661-8840
Practice Address - Fax:209-661-4843
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ASPIRANET
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-19
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA415200481251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health