Healthcare Provider Details

I. General information

NPI: 1790819068
Provider Name (Legal Business Name): RIVERSIADE COUNTY DEPT. OF MENTAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4275 LEMON ST
RIVERSIDE CA
92501-3844
US

IV. Provider business mailing address

9461 FLICKER AVE
FOUNTAIN VALLEY CA
92708-6543
US

V. Phone/Fax

Practice location:
  • Phone: 951-955-8541
  • Fax:
Mailing address:
  • Phone: 714-962-1040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License NumberA37158
License Number StateCA

VIII. Authorized Official

Name: MS. THERESA P FARJALLA
Title or Position: PSYCHIATRIST
Credential: M.D.
Phone: 951-955-4545