Healthcare Provider Details

I. General information

NPI: 1659634814
Provider Name (Legal Business Name): UNITED CEREBRAL PALSY OF SAN JOAQUIN, CALAVERAS, AMADOR INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2012
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 W BEN HOLT DR
STOCKTON CA
95207-3906
US

IV. Provider business mailing address

333 W BEN HOLT DR
STOCKTON CA
95207-3906
US

V. Phone/Fax

Practice location:
  • Phone: 209-751-3106
  • Fax: 209-751-3125
Mailing address:
  • Phone: 209-751-3106
  • Fax: 209-751-3125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateCA

VIII. Authorized Official

Name: MS. DEBBIE LINK
Title or Position: CLINICAL & FAMILY SERVICES DIRECTOR
Credential: BS OF OT
Phone: 209-751-3013