Healthcare Provider Details

I. General information

NPI: 1578384285
Provider Name (Legal Business Name): CRESTWOOD BEHAVIORAL HEALTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2024
Last Update Date: 01/22/2025
Certification Date: 01/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 S C ST
LOMPOC CA
93436-7305
US

IV. Provider business mailing address

7590 SHORELINE DR
STOCKTON CA
95219-5455
US

V. Phone/Fax

Practice location:
  • Phone: 888-868-1649
  • Fax:
Mailing address:
  • Phone: 209-955-2339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

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