Provider Demographics
NPI:1730317215
Name:SERENITY EATING DISORDER CLINIC OF CENTRAL CALIFORNIA
Entity type:Organization
Organization Name:SERENITY EATING DISORDER CLINIC OF CENTRAL CALIFORNIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:SUZANNE
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:559-760-5285
Mailing Address - Street 1:29613 JIM BOWIE CT
Mailing Address - Street 2:
Mailing Address - City:COARSEGOLD
Mailing Address - State:CA
Mailing Address - Zip Code:93614-9686
Mailing Address - Country:US
Mailing Address - Phone:559-760-5285
Mailing Address - Fax:
Practice Address - Street 1:29613 JIM BOWIE CT
Practice Address - Street 2:
Practice Address - City:COARSEGOLD
Practice Address - State:CA
Practice Address - Zip Code:93614-9686
Practice Address - Country:US
Practice Address - Phone:559-760-5285
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-23
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41576106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty