Healthcare Provider Details

I. General information

NPI: 1568604452
Provider Name (Legal Business Name): MENTAL HEALTH SUBSTANCE ABUSE PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2009
Last Update Date: 03/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

83912 AVENUE 45 STE 9
INDIO CA
92201-3338
US

IV. Provider business mailing address

83912 AVENUE 45 STE 9
INDIO CA
92201-3338
US

V. Phone/Fax

Practice location:
  • Phone: 760-347-0754
  • Fax: 760-347-8507
Mailing address:
  • Phone: 760-347-0754
  • Fax: 760-347-8507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberRW2331
License Number StateCA

VIII. Authorized Official

Name: MRS. MARYJO LOERA
Title or Position: BEHAVIORAL HEALTH SPECIALIST III
Credential: CCBADC/CAADAC
Phone: 760-347-0754