Provider Demographics
NPI:1801930920
Name:SOUTH COUNTY MENTAL HEALTH
Entity type:Organization
Organization Name:SOUTH COUNTY MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:831-454-4000
Mailing Address - Street 1:1400 EMELINE AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-1976
Mailing Address - Country:US
Mailing Address - Phone:831-454-4971
Mailing Address - Fax:831-454-4663
Practice Address - Street 1:1430 FREEDOM BLVD
Practice Address - Street 2:SUITE F
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-2780
Practice Address - Country:US
Practice Address - Phone:831-763-8200
Practice Address - Fax:831-454-4663
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF SANTA CRUZ
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-20
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QM0855X, 261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1659315430OtherLEGAL ENTITY NPI#
CAZZZ91891ZOtherCOUNTY OF SANTA CRUZ MEDICARE GROUP PTAN#
CA4475Medicaid
CAFHC70044FOtherSANTA CRUZ COUNTY MEDI-CAL GROUP NUNMBER