Healthcare Provider Details

I. General information

NPI: 1356798383
Provider Name (Legal Business Name): CHILDRENS CRISIS INTERVENTION PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2016
Last Update Date: 10/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 FLORIDA AVE STE 212
MODESTO CA
95350-4430
US

IV. Provider business mailing address

400 OYSTER POINT BLVD SUITE 501
SOUTH SAN FRANCISCO CA
94080-1904
US

V. Phone/Fax

Practice location:
  • Phone: 209-661-8840
  • Fax: 209-661-4843
Mailing address:
  • Phone: 650-866-4080
  • Fax: 650-866-4081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number415200481
License Number StateCA

VIII. Authorized Official

Name: MR. VERNON BROWN
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 650-866-4080