Healthcare Provider Details

I. General information

NPI: 1407768278
Provider Name (Legal Business Name): BOYS & GIRLS CLUB OF MANTECA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 W ALAMEDA ST
MANTECA CA
95336-3634
US

IV. Provider business mailing address

545 W ALAMEDA ST
MANTECA CA
95336-3634
US

V. Phone/Fax

Practice location:
  • Phone: 209-239-5437
  • Fax:
Mailing address:
  • Phone: 209-239-5437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MS. SARA YOUNG
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 209-239-5437