Provider Demographics
NPI:1699136440
Name:MARY MAGDALENE COMMUNITY SERVICES
Entity type:Organization
Organization Name:MARY MAGDALENE COMMUNITY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GENEVA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:209-888-4519
Mailing Address - Street 1:440 N EL DORADO ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95202-1950
Mailing Address - Country:US
Mailing Address - Phone:200-988-8451
Mailing Address - Fax:209-888-4535
Practice Address - Street 1:440 N EL DORADO ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-1950
Practice Address - Country:US
Practice Address - Phone:200-988-8451
Practice Address - Fax:209-888-4535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-08
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health