NPIMap

Organization Active NPI

Mendocino County

  • Adolescent and Children Mental Health Clinic/Center
  • Willits, CA
National Provider Identifier
1629107735
Registry record updated Jan 17, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Adolescent and Children Mental Health Clinic/CenterTaxonomy code 261QM0855X
Legal business name
MENDOCINO COUNTY
Practice address
474 E Valley St
Willits, CA 95490-3606
Phone
(707) 472-2300
Fax
(707) 472-2331
NPI assigned
Mar 5, 2007
Last updated
Jan 17, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 17, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Jenine Miller, PSY.D.
Title
BHRS Deputy Director
Phone
(707) 472-2300

Specialties & licenses 5

Specialty (taxonomy)CodeLicenseStatePrimary
Case Management Agency 251B00000X NU
Adult Mental Health Clinic/Center 261QM0850X NU
Adolescent and Children Mental Health Clinic/Center 261QM0855X NU Primary
Exclusive Provider Organization 302F00000X NU
Community/Behavioral Health Agency 251S00000X NU

Addresses

Primary practice location

474 E Valley St
Willits, CA 95490-3606

Mailing address

1120 S Dora St
Ukiah, CA 95482-6340
Phone (707) 472-2300

Other identifiers 3

IdentifierTypeStateIssuer
BBB33295BOtherCAMH SUBMITTER #
00023MedicaidCA
2367MedicaidCA

Other names 1

  • Behavioral Health & Recovery Services - Mental Health Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040520001485 CA Part B Supplier - Clinic/Group Practice 8325033301 Receives reassigned benefits from 1 practitioner
2 other NPIs on this enrollment
Practice locations: Fort Bragg, CA; Willits, CA; Ukiah, CA

Other NPIs on the same Medicare enrollment 2

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Mendocino County Health12 organizations share this tax ID, including this one

Other organizations with this tax ID 11

Organizations that report the same tax identification number in the National Provider Directory.

Locations

125 E Commercial St
Ste 200
Willits, CA 95490
Phone (707) 472-2637

474 E Valley St
Willits, CA 95490
Phone (707) 456-3857

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1173052800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1705449600000",
    "number": "1629107735",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1120 S DORA ST",
            "city": "UKIAH",
            "state": "CA",
            "postal_code": "954826340",
            "telephone_number": "707-472-2300",
            "fax_number": "707-472-2331"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "474 E VALLEY ST",
            "city": "WILLITS",
            "state": "CA",
            "postal_code": "954903606",
            "telephone_number": "707-472-2300",
            "fax_number": "707-472-2331"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MENDOCINO COUNTY",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-05",
        "last_updated": "2024-01-17",
        "certification_date": "2024-01-17",
        "status": "A",
        "authorized_official_last_name": "MILLER",
        "authorized_official_first_name": "JENINE",
        "authorized_official_title_or_position": "BHRS DEPUTY DIRECTOR",
        "authorized_official_telephone_number": "707-472-2300",
        "authorized_official_credential": "PSY.D."
    },
    "taxonomies": [
        {
            "code": "251B00000X",
            "taxonomy_group": "",
            "desc": "Case Management",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QM0850X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Adult Mental Health",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QM0855X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Adolescent and Children Mental Health",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "302F00000X",
            "taxonomy_group": "",
            "desc": "Exclusive Provider Organization",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "251S00000X",
            "taxonomy_group": "",
            "desc": "Community/Behavioral Health",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MH SUBMITTER #",
            "identifier": "BBB33295B",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00023",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2367",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Behavioral Health & Recovery Services - Mental Health",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Willits, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 17, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.