Provider Demographics
NPI:1730367178
Name:SENIOR SUPPORT PROGRAM OF THE TRI VALLEY
Entity type:Organization
Organization Name:SENIOR SUPPORT PROGRAM OF THE TRI VALLEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARLENE
Authorized Official - Middle Name:J
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-931-5378
Mailing Address - Street 1:5353 SUNOL BLVD
Mailing Address - Street 2:
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94566-7607
Mailing Address - Country:US
Mailing Address - Phone:925-931-5379
Mailing Address - Fax:
Practice Address - Street 1:5353 SUNOL BLVD
Practice Address - Street 2:
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94566-7607
Practice Address - Country:US
Practice Address - Phone:925-931-5379
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-07
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2758503251B00000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management