Provider Demographics
NPI:1053540195
Name:DALY CITY YOUTH HEALTH CENTER
Entity type:Organization
Organization Name:DALY CITY YOUTH HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MFTI
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:MITCHELL
Authorized Official - Last Name:STULLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:650-550-7678
Mailing Address - Street 1:2780 JUNIPERO SERRA BLVD
Mailing Address - Street 2:
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-1634
Mailing Address - Country:US
Mailing Address - Phone:650-985-7000
Mailing Address - Fax:
Practice Address - Street 1:2780 JUNIPERO SERRA BLVD
Practice Address - Street 2:
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-1634
Practice Address - Country:US
Practice Address - Phone:650-985-7000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-10
Last Update Date:2009-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58560251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health