Healthcare Provider Details

I. General information

NPI: 1265897029
Provider Name (Legal Business Name): REDWOOD COMMUNITY SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2015
Last Update Date: 01/21/2020
Certification Date: 01/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 1ST ST
UPPER LAKE CA
95485
US

IV. Provider business mailing address

PO BOX 2077 631 S. ORCHARD STREET
UKIAH CA
95482-2077
US

V. Phone/Fax

Practice location:
  • Phone: 707-275-8776
  • Fax:
Mailing address:
  • Phone: 707-467-2010
  • Fax: 707-463-4931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MRS. VICTORIA JERSUHA KELLY
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: LCSW
Phone: 707-467-2010