Healthcare Provider Details

I. General information

NPI: 1629771811
Provider Name (Legal Business Name): CRESTWOOD BEHAVIORAL HEALTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2023
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2178 JOHNSON AVE
SAN LUIS OBISPO CA
93401-4535
US

IV. Provider business mailing address

7590 SHORELINE DR
STOCKTON CA
95219-5455
US

V. Phone/Fax

Practice location:
  • Phone: 209-955-2364
  • Fax: 209-671-1520
Mailing address:
  • Phone: 209-955-2339
  • Fax: 209-671-1520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE SMITH
Title or Position: EXECUTIVE DIRECTOR AR AND REIMB.
Credential:
Phone: 209-955-2364