Provider Demographics
NPI:1578003711
Name:THE PARENT COOPERATIVE COMMUNITY
Entity type:Organization
Organization Name:THE PARENT COOPERATIVE COMMUNITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEROSE
Authorized Official - Suffix:
Authorized Official - Credentials:MA, MFT
Authorized Official - Phone:916-965-5135
Mailing Address - Street 1:4426 ILLINOIS AVE
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-6307
Mailing Address - Country:US
Mailing Address - Phone:916-965-5135
Mailing Address - Fax:916-947-0371
Practice Address - Street 1:4426 ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-6307
Practice Address - Country:US
Practice Address - Phone:916-965-5135
Practice Address - Fax:916-947-0371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-07
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA347004337322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children