Provider Demographics
NPI:1992233159
Name:MENDOCINO COUNTY YOUTH PROJECT
Entity type:Organization
Organization Name:MENDOCINO COUNTY YOUTH PROJECT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CLINICAL PROGRAM
Authorized Official - Prefix:
Authorized Official - First Name:MIMINE
Authorized Official - Middle Name:
Authorized Official - Last Name:AMBROIS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:707-463-4915
Mailing Address - Street 1:776 S STATE ST STE 107
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-5858
Mailing Address - Country:US
Mailing Address - Phone:707-463-4915
Mailing Address - Fax:
Practice Address - Street 1:376 E GOBBI ST STE B
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-5511
Practice Address - Country:US
Practice Address - Phone:707-463-4915
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-31
Last Update Date:2017-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA94-2882841Medicaid