Provider Demographics
NPI:1972095701
Name:CRESTWOOD BEHAVIORAL HEALTH,INC
Entity type:Organization
Organization Name:CRESTWOOD BEHAVIORAL HEALTH,INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CAO/TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKBURN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-955-2322
Mailing Address - Street 1:7590 SHORELINE DR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-5455
Mailing Address - Country:US
Mailing Address - Phone:209-955-2328
Mailing Address - Fax:209-644-5721
Practice Address - Street 1:2101 COURAGE DR
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533
Practice Address - Country:US
Practice Address - Phone:209-955-2328
Practice Address - Fax:209-644-5721
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CRESTWOOD BEHAVIORAL HEALTH INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-06-06
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)