Healthcare Provider Details

I. General information

NPI: 1528496619
Provider Name (Legal Business Name): REDWOOD COMMUNITY SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2013
Last Update Date: 02/14/2023
Certification Date: 02/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 CYPRESS STREET
FORT BRAGG CA
95437-5107
US

IV. Provider business mailing address

PO BOX 2077 780 S. DORA STREET
UKIAH CA
95482-2077
US

V. Phone/Fax

Practice location:
  • Phone: 707-961-0308
  • Fax: 707-961-0351
Mailing address:
  • Phone: 707-961-0308
  • Fax: 707-961-0351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State

VIII. Authorized Official

Name: MRS. VICTORIA JERUSHA KELLY
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: LCSW
Phone: 707-467-2010