Healthcare Provider Details

I. General information

NPI: 1710398250
Provider Name (Legal Business Name): LIFTED FOUNDATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2014
Last Update Date: 11/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8363 RESEDA BLVD SUITE 203 E
NORTHRIDGE CA
91324-4623
US

IV. Provider business mailing address

8363 RESEDA BLVD SUITE 203 E
NORTHRIDGE CA
91324-4623
US

V. Phone/Fax

Practice location:
  • Phone: 818-727-7742
  • Fax:
Mailing address:
  • Phone: 818-727-7742
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License NumberLCS 23309
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberLCS 23309
License Number StateCA

VIII. Authorized Official

Name: MS. TANYATTA CHATEAU
Title or Position: CLINICAL SOCIAL WORKER/ MANAGER
Credential: LCSW
Phone: 818-606-9836