Healthcare Provider Details

I. General information

NPI: 1104941442
Provider Name (Legal Business Name): ETTIE LEE YOUTH AND FAMILY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12345 CHANDLER BLVD
NORTH HOLLYWOOD CA
91607-2079
US

IV. Provider business mailing address

10621 VALLEY SPRING LN #305
TOLUCA LAKE CA
91602-3200
US

V. Phone/Fax

Practice location:
  • Phone: 818-760-0665
  • Fax: 818-760-0157
Mailing address:
  • Phone: 818-760-9548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number#50219
License Number StateCA

VIII. Authorized Official

Name: MS. LEANE CATHERINE SHILLING
Title or Position: THERAPEUTIC SOCIAL WORKER
Credential: M.S., IMF
Phone: 818-915-5497