MEDICARE: LIFTED FOUNDATION LLC

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	251S00000X	Community/Behavioral Health Agency	LCS 23309	CA
2	251B00000X	Case Management Agency	LCS 23309	CA

General Provider Information

NPI Number	:	1710398250
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFTED FOUNDATION LLC

Provider Business Mailing Address
First Line	:	8363 RESEDA BLVD
Second Line	:	SUITE 203 E
City	:	NORTHRIDGE
State	:	CA
Zip	:	91324-4623
Country	:	US
Telephone Number	:	818-727-7742
Fax Number	:

Provider Business Practice Location Address
First Line	:	8363 RESEDA BLVD
Second Line	:	SUITE 203 E
City	:	NORTHRIDGE
State	:	CA
Zip	:	91324-4623
Country	:	US
Telephone Number	:	818-727-7742
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL SOCIAL WORKER/ MANAGER
Name	:	MS. TANYATTA CHATEAU
Credential	:	LCSW
Telephone Number	:	818-606-9836

Provider Enumeration Date	:	05/19/2014
Last Update Date	:	11/05/2014

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