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Organization
SAN QUENTIN
Active
Organization
SAN QUENTIN
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. CHRISTOPHER ROACH PSYCH. D (SUPERVISOR)
(415) 454-1460
Entity
Organization
Contact information
Practice address
1635 JOSEPHINE ST, BERKELEY, CA 94703-1320
(415) 454-1469
Mailing address
1635 JOSEPHINE ST, BERKELEY, CA 94703-1320
(415) 454-1469
Taxonomy
Speciality
Code
Description
License number
State
251B00000X
Case Management Agency
Primary
—
NULL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
LCS14462
LCSW
CA
Enumeration date
07/29/2013
Last updated
07/29/2013
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