Healthcare Provider Details

I. General information

NPI: 1063567378
Provider Name (Legal Business Name): CSP CRISIS RESIDENTIAL PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 CATALINA
LAGUNA BEACH CA
92651-2748
US

IV. Provider business mailing address

980 CATALINA
LAGUNA BEACH CA
92651-2748
US

V. Phone/Fax

Practice location:
  • Phone: 949-494-4311
  • Fax:
Mailing address:
  • Phone: 949-494-4311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License NumberMFT35212
License Number StateCA

VIII. Authorized Official

Name: MRS. CAROL CARLSON
Title or Position: DIRECTOR
Credential:
Phone: 949-494-4311