Provider Demographics
NPI:1215125026
Name:LAKE COUNTY COMMUNITY ACTION AGENCY
Entity type:Organization
Organization Name:LAKE COUNTY COMMUNITY ACTION AGENCY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:M
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:CADAC II
Authorized Official - Phone:707-995-3235
Mailing Address - Street 1:6885 OLD HWY 53
Mailing Address - Street 2:PO BOX 6470
Mailing Address - City:CLEARLAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95422
Mailing Address - Country:US
Mailing Address - Phone:707-995-3235
Mailing Address - Fax:707-995-7004
Practice Address - Street 1:6840 S CENTER DR
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-8134
Practice Address - Country:US
Practice Address - Phone:707-995-1232
Practice Address - Fax:707-995-7084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-05
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA170010AN251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health