Healthcare Provider Details

I. General information

NPI: 1902930332
Provider Name (Legal Business Name): PACIFIC LODGE YOUTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 SERRANIA AVE
WOODLAND HILLS CA
91364-3301
US

IV. Provider business mailing address

4900 SERRANIA AVE
WOODLAND HILLS CA
91364-3301
US

V. Phone/Fax

Practice location:
  • Phone: 818-657-3104
  • Fax: 818-347-0184
Mailing address:
  • Phone: 818-657-3104
  • Fax: 818-347-0184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: LISA E ALEGRIA
Title or Position: PRESIDENT CEO
Credential:
Phone: 818-657-3104