Healthcare Provider Details

I. General information

NPI: 1245052760
Provider Name (Legal Business Name): MIXED BEHAVIOR FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2024
Last Update Date: 10/28/2024
Certification Date: 10/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6955 FOOTHILL BLVD # 275
OAKLAND CA
94605-2455
US

IV. Provider business mailing address

2872 YGNACIO VALLEY RD # 439
WALNUT CREEK CA
94598-3534
US

V. Phone/Fax

Practice location:
  • Phone: 925-430-8295
  • Fax:
Mailing address:
  • Phone: 925-430-8295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: SASHA JACKSON
Title or Position: EXECUTIVE DIRECTOR/CFO
Credential:
Phone: 925-430-8295