MEDICARE: FAMILY SERVICE OF THE TRI-CITIES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor		CA

General Provider Information

NPI Number	:	1912060393
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY SERVICE OF THE TRI-CITIES

Provider Business Mailing Address
First Line	:	39899 BALENTINE DR
Second Line	:	SUITE 212
City	:	NEWARK
State	:	CA
Zip	:	94560-5355
Country	:	US
Telephone Number	:	510-791-3322
Fax Number	:	510-791-3325

Provider Business Practice Location Address
First Line	:	39899 BALENTINE DR
Second Line	:	SUITE 212
City	:	NEWARK
State	:	CA
Zip	:	94560-5355
Country	:	US
Telephone Number	:	510-791-3322
Fax Number	:	510-791-3325

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	INGRID J THERIAULT
Credential	:
Telephone Number	:	510-791-3322

Provider Enumeration Date	:	12/18/2006
Last Update Date	:	10/01/2009

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Directions to “FAMILY SERVICE OF THE TRI-CITIES ” Practice Location

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