Healthcare Provider Details

I. General information

NPI: 1093418048
Provider Name (Legal Business Name): MARY MAGDALENE COMMUNITY SERVICES AGENCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2023
Last Update Date: 09/12/2023
Certification Date: 09/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 N AURORA ST STE 7
STOCKTON CA
95202-2276
US

IV. Provider business mailing address

620 N AURORA ST STE 7
STOCKTON CA
95202-2276
US

V. Phone/Fax

Practice location:
  • Phone: 209-888-4519
  • Fax:
Mailing address:
  • Phone: 209-888-4519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: MRS. GENEVA HAYNES
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 209-888-4519