Basic Information
| Provider Information | |||||||||
| NPI: | 1326614009 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE TEEN PROJECT, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | TEEN PROJECT DRUG TREATMENT CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 22431 ANTONIO PKWY STE 527 | ||||||||
| Address2: | |||||||||
| City: | RSM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926882804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9492831260 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 20302 FLANAGAN ROAD | ||||||||
| Address2: | |||||||||
| City: | TRABUCO CANYON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92679 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9492831260 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2021 | ||||||||
| LastUpdateDate: | 11/02/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BURNS | ||||||||
| AuthorizedOfficialFirstName: | LAURI | ||||||||
| AuthorizedOfficialMiddleName: | LYNNE | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9492831260 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THE TEEN PROJECT | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.