Provider Demographics
NPI:1104941442
Name:ETTIE LEE YOUTH AND FAMILY SERVICES
Entity type:Organization
Organization Name:ETTIE LEE YOUTH AND FAMILY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPEUTIC SOCIAL WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:LEANE
Authorized Official - Middle Name:CATHERINE
Authorized Official - Last Name:SHILLING
Authorized Official - Suffix:
Authorized Official - Credentials:MS, IMF
Authorized Official - Phone:818-915-5497
Mailing Address - Street 1:10621 VALLEY SPRING LN
Mailing Address - Street 2:#305
Mailing Address - City:TOLUCA LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:91602-3200
Mailing Address - Country:US
Mailing Address - Phone:818-760-9548
Mailing Address - Fax:
Practice Address - Street 1:12345 CHANDLER BLVD
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91607-2079
Practice Address - Country:US
Practice Address - Phone:818-760-0665
Practice Address - Fax:818-760-0157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA#50219322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children