Healthcare Provider Details

I. General information

NPI: 1245814151
Provider Name (Legal Business Name): VARSITY TEAM, INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2021
Last Update Date: 05/06/2021
Certification Date: 05/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 S 18TH ST
BRAWLEY CA
92227-2859
US

IV. Provider business mailing address

PO BOX 26633
SAN DIEGO CA
92196-0633
US

V. Phone/Fax

Practice location:
  • Phone: 760-623-7131
  • Fax: 619-362-9532
Mailing address:
  • Phone: 619-694-6809
  • Fax: 619-362-9532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: DREW DAHLSTEDT
Title or Position: CFO/COO
Credential:
Phone: 619-694-6809