Basic Information
| Provider Information | |||||||||
| NPI: | 1336272111 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ETTIE LEE YOUTH FAMILY SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14101 VAI BROTHERS DR | ||||||||
| Address2: | |||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917392172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098991435 | ||||||||
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| Practice Location | |||||||||
| Address1: | ETTIE LEE 5146 N. MAINE AVE. | ||||||||
| Address2: | |||||||||
| City: | BALDWIN PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096202521 | ||||||||
| FaxNumber: | 9096209793 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BAKER | ||||||||
| AuthorizedOfficialFirstName: | DIANA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROGRAM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9095033589 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | A3813299 | CA | X | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 103TC2200X | CA | X | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
No ID Information.