=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255789855
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RIVERSIDE COUNTY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2016
-----------------------------------------------------
Last Update Date | 05/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3625 14TH ST
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92501-3815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-955-1540
-----------------------------------------------------
Fax | 951-955-1610
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3625 14TH ST
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92501-3815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-955-1540
-----------------------------------------------------
Fax | 951-955-1610
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. CLAUDIA SMITH
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 951-955-1540
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302R00000X
-----------------------------------------------------
Taxonomy Name | Health Maintenance Organization
-----------------------------------------------------
License Number | LMFT48591
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------