Provider Demographics
NPI:1578861761
Name:COUNTY OF LAKE
Entity type:Organization
Organization Name:COUNTY OF LAKE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DEPARTMENT HEAD
Authorized Official - Prefix:
Authorized Official - First Name:KRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MFT
Authorized Official - Phone:707-263-4338
Mailing Address - Street 1:991 PARALLEL DR.
Mailing Address - Street 2:STE. B
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-5717
Mailing Address - Country:US
Mailing Address - Phone:707-263-8162
Mailing Address - Fax:707-263-9336
Practice Address - Street 1:9345 WINCHESTER ST
Practice Address - Street 2:
Practice Address - City:LOWER LAKE
Practice Address - State:CA
Practice Address - Zip Code:95457-5000
Practice Address - Country:US
Practice Address - Phone:707-994-6494
Practice Address - Fax:707-994-7092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-11
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA170002BN261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder