Healthcare Provider Details

I. General information

NPI: 1982809117
Provider Name (Legal Business Name): 95WESTERN YOUTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 06/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10101 SLATER AVE STE 241
FOUNTAIN VALLEY CA
92708-4723
US

IV. Provider business mailing address

10101 SLATER AVE STE 241
FOUNTAIN VALLEY CA
92708-4723
US

V. Phone/Fax

Practice location:
  • Phone: 714-378-2620
  • Fax: 714-378-2631
Mailing address:
  • Phone: 714-378-2620
  • Fax: 714-378-2631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: MAGGIE ROSS
Title or Position: THERAPIST
Credential: MSW
Phone: 714-378-2620