Basic Information
| Provider Information | |||||||||
| NPI: | 1437609773 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WESTSIDE SOBER LIVING CENTERS, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PROMISES PTP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 670549 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752670549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6155677282 | ||||||||
| FaxNumber: | 6152618912 | ||||||||
| Practice Location | |||||||||
| Address1: | 2515 WILSHIRE BLVD | ||||||||
| Address2: | |||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904034615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8665953105 | ||||||||
| FaxNumber: | 4242729303 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2016 | ||||||||
| LastUpdateDate: | 10/11/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MAPLESDEN | ||||||||
| AuthorizedOfficialFirstName: | CHERYL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SR DIRECTOR RCM | ||||||||
| AuthorizedOfficialTelephone: | 6155103708 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ELEMENTS BEHAVIORAL HEALTH, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CPC, CHC, CHPC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 190625GP | CA | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.