Healthcare Provider Details

I. General information

NPI: 1629406103
Provider Name (Legal Business Name): BHS CHILDREN AND YOUTH SERV
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2013
Last Update Date: 10/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 N CALIFORNIA ST
STOCKTON CA
95202-1552
US

IV. Provider business mailing address

1212 N CALIFORNIA ST
STOCKTON CA
95202-1552
US

V. Phone/Fax

Practice location:
  • Phone: 209-468-2385
  • Fax:
Mailing address:
  • Phone: 209-468-2385
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License NumberASW 28264
License Number StateCA

VIII. Authorized Official

Name: MS. LORNA STEPHANIE TRUJILLO
Title or Position: MHC1
Credential: ASW
Phone: 209-468-4240