MEDICARE: EAST VALLEY CHARLEE, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility

General Provider Information

NPI Number	:	1528641511
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST VALLEY CHARLEE, INC.

Provider Business Mailing Address
First Line	:	101 E. REDLANDS BLVD
Second Line	:	SUITE 285
City	:	REDLANDS
State	:	CA
Zip	:	92373
Country	:	US
Telephone Number	:	909-307-5777
Fax Number	:	909-307-5776

Provider Business Practice Location Address
First Line	:	35895 SANTA MARIA ST.
Second Line	:
City	:	YUCAIPA
State	:	CA
Zip	:	92399-5504
Country	:	US
Telephone Number	:	909-795-8656
Fax Number	:	909-307-5776

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	TINA COLLINS
Credential	:	LMFT
Telephone Number	:	909-307-5777

Provider Enumeration Date	:	04/28/2021
Last Update Date	:	12/24/2025

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