Healthcare Provider Details

I. General information

NPI: 1639204977
Provider Name (Legal Business Name): BEHAVIORAL HEALTH MED ASSOC CHO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 52ND ST
OAKLAND CA
94609-1809
US

IV. Provider business mailing address

3116 W MARCH LN STE 200
STOCKTON CA
95219-2369
US

V. Phone/Fax

Practice location:
  • Phone: 510-428-3351
  • Fax: 510-601-3912
Mailing address:
  • Phone: 209-473-6555
  • Fax: 209-473-6543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License NumberG85795
License Number StateCA

VIII. Authorized Official

Name: RENEE WACHTEL
Title or Position: HEAD OF DEPT
Credential: MD
Phone: 510-428-3351