=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174677116
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONTRA COSTA COUNTY HEALTH SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2007
-----------------------------------------------------
Last Update Date | 08/08/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1420 WILLOW PASS RD SUITE 200
-----------------------------------------------------
City | CONCORD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94520-5223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-646-5480
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1420 WILLOW PASS RD SUITE 200
-----------------------------------------------------
City | CONCORD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94520-5223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-646-5480
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MENTAL HEALTH PROG MANAGER
-----------------------------------------------------
Name | MR. JOHN DAVID ALLEN
-----------------------------------------------------
Credential | M.F.T.
-----------------------------------------------------
Telephone | 925-646-5480
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFC 18702
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------