Healthcare Provider Details

I. General information

NPI: 1023495181
Provider Name (Legal Business Name): CRESTWOOD BEHAVIORAL HEALTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2015
Last Update Date: 11/30/2023
Certification Date: 11/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 THIRD AVE
CHULA VISTA CA
91911
US

IV. Provider business mailing address

7590 SHORELINE DR
STOCKTON CA
95219-5455
US

V. Phone/Fax

Practice location:
  • Phone: 209-478-5291
  • Fax:
Mailing address:
  • Phone: 209-478-5291
  • Fax: 209-952-5314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310500000X
TaxonomyMental Illness Intermediate Care Facility
License Number
License Number State

VIII. Authorized Official

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