=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609065523
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HUCKLEBERRY YOUTH PROGRAMS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2007
-----------------------------------------------------
Last Update Date | 06/17/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9 GROVE LN
-----------------------------------------------------
City | SAN ANSELMO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94960-2102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-453-5200
-----------------------------------------------------
Fax | 415-453-8418
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9 GROVE LN
-----------------------------------------------------
City | SAN ANSELMO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94960-2102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-453-5200
-----------------------------------------------------
Fax | 415-453-8418
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF PROGRAMS AND OPERATIONS
-----------------------------------------------------
Name | VIRGINIA PRICE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 415-668-2622
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 210102876
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------