Healthcare Provider Details

I. General information

NPI: 1275210239
Provider Name (Legal Business Name): OC TEEN ADDICTION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2023
Last Update Date: 03/18/2026
Certification Date: 03/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1940 W ORANGEWOOD AVE STE 206
ORANGE CA
92868-5037
US

IV. Provider business mailing address

1101 W STEVENS AVE APT 5
SANTA ANA CA
92707-5040
US

V. Phone/Fax

Practice location:
  • Phone: 714-474-8655
  • Fax: 949-203-2151
Mailing address:
  • Phone: 714-474-8655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RUEBEN GRAJEDA
Title or Position: FOUNDER
Credential: BSM
Phone: 714-474-8655