Basic Information
| Provider Information | |||||||||
| NPI: | 1245458546 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ETTIE LEE HOMES, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ETTIE LEE - COVINA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5146 MAINE AVE | ||||||||
| Address2: | P.O.BOX 339 | ||||||||
| City: | BALDWIN PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917061658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269604861 | ||||||||
| FaxNumber: | 6269606241 | ||||||||
| Practice Location | |||||||||
| Address1: | 754 E ARROW HWY | ||||||||
| Address2: | SUITE F | ||||||||
| City: | COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917222107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269675082 | ||||||||
| FaxNumber: | 6268595002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2007 | ||||||||
| LastUpdateDate: | 07/29/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VARNUM | ||||||||
| AuthorizedOfficialFirstName: | TERRI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 6269604861 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | 197802737 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 7453A | 01 | CA | MENTAL HEALTH | OTHER | 7008 | 01 | CA | DRUG & ALCOHOL | OTHER | 7712 | 01 | CA | OTHER - MENTAL HEALTH | OTHER |