Provider Demographics
NPI:1356529663
Name:DEPARTMENT OF HEALTH SERVICES - MENTAL HEALTH
Entity type:Organization
Organization Name:DEPARTMENT OF HEALTH SERVICES - MENTAL HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE ACCOUNTANT III
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:L
Authorized Official - Last Name:STORNETTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-565-4782
Mailing Address - Street 1:100 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:CLOVERDALE
Mailing Address - State:CA
Mailing Address - Zip Code:95425-3204
Mailing Address - Country:US
Mailing Address - Phone:187-770-0527
Mailing Address - Fax:
Practice Address - Street 1:100 W 3RD ST
Practice Address - Street 2:
Practice Address - City:CLOVERDALE
Practice Address - State:CA
Practice Address - Zip Code:95425-3204
Practice Address - Country:US
Practice Address - Phone:187-770-0527
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DEPARTMENT OF HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-08
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA49CC1OtherCA STATE MEDI-CAL RU