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General NPI Number Information
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NPI Number | 1578003711
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Entity Type | Organization
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Legal Business Name | THE PARENT COOPERATIVE COMMUNITY
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Dates
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Enumeration Date | 03/07/2017
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Last Update Date | 03/07/2017
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Provider Practice Location Address
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Address Line | 4426 ILLINOIS AVE
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City | FAIR OAKS
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State | CA
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Zip | 95628-6307
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Country | US
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Telephone | 916-965-5135
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Fax | 916-947-0371
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Provider Business Mailing Address
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Address Line | 4426 ILLINOIS AVE
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City | FAIR OAKS
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State | CA
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Zip | 95628-6307
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Country | US
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Telephone | 916-965-5135
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Fax | 916-947-0371
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Authorized Official
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Title or Position | DIRECTOR
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Name | MS. CARLA DEROSE
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Credential | MA, MFT
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Telephone | 916-965-5135
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number | 347004337
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License Number State | CA
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