Healthcare Provider Details

I. General information

NPI: 1104905645
Provider Name (Legal Business Name): CRESTWOOD BEHAVIORAL HEALTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 11/30/2023
Certification Date: 11/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4741 ENGLE RD
CARMICHAEL CA
95608-2223
US

IV. Provider business mailing address

7590 SHORELINE DR
STOCKTON CA
95219-5455
US

V. Phone/Fax

Practice location:
  • Phone: 916-977-0948
  • Fax: 916-483-3071
Mailing address:
  • Phone: 209-955-2328
  • Fax: 209-952-5314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE SMITH
Title or Position: EXECUTIVE DIRECTOR AR AND REIMB.
Credential:
Phone: 209-955-2364