Provider Demographics
NPI:1831907518
Name:BOYS & GIRLS CLUBS OF GREATER REDLANDS-RIVERSIDE
Entity type:Organization
Organization Name:BOYS & GIRLS CLUBS OF GREATER REDLANDS-RIVERSIDE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIR. OF BEHAVIORAL HEALTH SERVICES
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:IRENE
Authorized Official - Last Name:DAGGETT
Authorized Official - Suffix:
Authorized Official - Credentials:DSW, MS, LMFT
Authorized Official - Phone:909-731-5576
Mailing Address - Street 1:1251 CLAY ST
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-3257
Mailing Address - Country:US
Mailing Address - Phone:909-731-5576
Mailing Address - Fax:
Practice Address - Street 1:1251 CLAY ST
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-3257
Practice Address - Country:US
Practice Address - Phone:909-731-5576
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-26
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)