Provider Demographics
NPI:1619136132
Name:CONTRA COSTA YOUTH SERVICE BUREAU
Entity type:Organization
Organization Name:CONTRA COSTA YOUTH SERVICE BUREAU
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL MANAGER OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MILDRED
Authorized Official - Middle Name:NAIMA
Authorized Official - Last Name:WALLS-JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:510-825-7994
Mailing Address - Street 1:186 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94804-1949
Mailing Address - Country:US
Mailing Address - Phone:510-215-4670
Mailing Address - Fax:
Practice Address - Street 1:700 W 1ST ST
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-1109
Practice Address - Country:US
Practice Address - Phone:925-246-0300
Practice Address - Fax:925-246-0303
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CONTRA COSTA YOUTH SERVICE BUREAU
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-09
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA01919506Medicaid