Healthcare Provider Details

I. General information

NPI: 1710695986
Provider Name (Legal Business Name): THE TEEN PROJECT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2022
Last Update Date: 11/07/2022
Certification Date: 10/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20342 FLANAGAN ROAD
TRABUCO CANYON CA
92679
US

IV. Provider business mailing address

22431 B160 ANTONIO PARKWAY, SUITE 527
RANCHO SANTA MARGARITA CA
92679-3948
US

V. Phone/Fax

Practice location:
  • Phone: 800-685-7460
  • Fax:
Mailing address:
  • Phone: 949-283-1260
  • Fax: 818-582-8836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: LAURI LYNNE BURNS
Title or Position: CEO
Credential:
Phone: 818-582-8832