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23000 Henderson Lane Covelo CA 95428-0247 | |
| (707) 983-6404 | |
| (707) 983-6184 |
| Full Name | |
|---|---|
| Speciality | Clinic/center - Mental Health (including Community Mental Health Center) |
| Location | 23000 Henderson Lane, Covelo, California |
| Authorized Official Name and Position | Otis Brotherton (EXECUTIVE DIRECTOR) |
| Authorized Official Contact | 7079836404 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
Po Box 247 Covelo CA 95428-0247 Ph: (707) 983-6404 | 23000 Henderson Lane Covelo CA 95428-0247 Ph: (707) 983-6404 |
| NPI Number | 1114136066 |
|---|---|
| Provider Enumeration Date | 05/21/2007 |
| Last Update Date | 03/13/2024 |
| Certification Date | 03/13/2024 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1114136066 | NPI | - | NPPES |
| THP11697F | Medicaid | CA |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM0801X | Clinic/center - Mental Health (including Community Mental Health Center) | 230007AN (California) | Primary |