Healthcare Provider Details

I. General information

NPI: 1508111097
Provider Name (Legal Business Name): FRED FINCH YOUTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2012
Last Update Date: 09/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

637 3RD AVE SUITE 1
CHULA VISTA CA
91910-5707
US

IV. Provider business mailing address

637 3RD AVE SUITE 1
CHULA VISTA CA
91910-5707
US

V. Phone/Fax

Practice location:
  • Phone: 619-873-4075
  • Fax: 619-621-2268
Mailing address:
  • Phone: 619-873-4075
  • Fax: 619-621-2268

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 Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MR. THOMAS N ALEXANDER
Title or Position: PRESIDENT AND CEO
Credential: LCSW
Phone: 510-482-2244