Healthcare Provider Details

I. General information

NPI: 1528277399
Provider Name (Legal Business Name): LAKE COUNTY MENTAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20785 NAPA AVE
MIDDLETOWN CA
95461-9706
US

IV. Provider business mailing address

20785 NAPA AVE
MIDDLETOWN CA
95461-9706
US

V. Phone/Fax

Practice location:
  • Phone: 707-987-0199
  • Fax:
Mailing address:
  • Phone: 707-987-0199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number101YM0800X
License Number StateCA

VIII. Authorized Official

Name: TERENCE ROOONEY
Title or Position: CHILDRENS COORDINATOR
Credential: MFT
Phone: 707-994-7090