=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245482207
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SANTA PAULA BEHAVIORAL HEALTH CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2008
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 333 W HARVARD BLVD
-----------------------------------------------------
City | SANTA PAULA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93060-3225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-933-4868
-----------------------------------------------------
Fax | 805-933-4860
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 800 S VICTORIA AVE # L4615
-----------------------------------------------------
City | VENTURA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93009-0003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-677-5210
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF DEPUTY DIRECTOR
-----------------------------------------------------
Name | KIM MILSTIEN
-----------------------------------------------------
Credential | MFT
-----------------------------------------------------
Telephone | 805-652-6058
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------