Healthcare Provider Details

I. General information

NPI: 1326536632
Provider Name (Legal Business Name): FIRST BAPTIST CHURCH OF LODI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2018
Last Update Date: 04/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 W LOCKEFORD ST
LODI CA
95240-2125
US

IV. Provider business mailing address

17 W LOCKEFORD ST
LODI CA
95240-2125
US

V. Phone/Fax

Practice location:
  • Phone: 209-339-1616
  • Fax:
Mailing address:
  • Phone: 209-339-1616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number1425
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number101549
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: ALISON MCGREGOR
Title or Position: EXEC DIR ONE-EIGHTY YOUTH PROGRAMS
Credential: MFT
Phone: 209-339-1616