=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811020001
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEVADA COUNTY BEHAVIORAL HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2007
-----------------------------------------------------
Last Update Date | 08/13/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 208 SUTTON WAY
-----------------------------------------------------
City | GRASS VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95945-4144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-265-7147
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18950 JAYHAWK DR
-----------------------------------------------------
City | PENN VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95946-9218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST
-----------------------------------------------------
Name | MR. CURTIS BARON MCMULLAN
-----------------------------------------------------
Credential | MFT
-----------------------------------------------------
Telephone | 530-265-5811
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 47100
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------