=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083530596
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHOENIX HOUSE CALIFORNIA - LAKE VIEW TERRACE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2026
-----------------------------------------------------
Last Update Date | 06/29/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11600 ELDRIDGE AVE
-----------------------------------------------------
City | LAKE VIEW TERRACE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91342-6506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-686-3000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11600 ELDRIDGE AVE
-----------------------------------------------------
City | LAKE VIEW TERRACE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91342-6506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-686-3000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MARRIAGE & FAMILY THERAPIST
-----------------------------------------------------
Name | JORDAN HOUSE GOLDSTEIN
-----------------------------------------------------
Credential | AMFT
-----------------------------------------------------
Telephone | 657-270-4960
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------