Healthcare Provider Details

I. General information

NPI: 1780762989
Provider Name (Legal Business Name): CANYON LAKES RESIDENTIAL TREATMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2402 CANYON LAKES DR
LUBBOCK TX
79415-2000
US

IV. Provider business mailing address

2402 CANYON LAKES DR
LUBBOCK TX
79415-2000
US

V. Phone/Fax

Practice location:
  • Phone: 806-762-5782
  • Fax: 806-762-0838
Mailing address:
  • Phone: 806-762-5782
  • Fax: 806-762-0838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: LENISE L STAHA
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 806-762-5782