Provider Demographics
NPI:1285916882
Name:EGGLESTON YOUTH CENTERS, INC.
Entity type:Organization
Organization Name:EGGLESTON YOUTH CENTERS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:GIBSON-JUDKINS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:626-480-8107
Mailing Address - Street 1:3001 W VERNON AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90008-5293
Mailing Address - Country:US
Mailing Address - Phone:323-299-9554
Mailing Address - Fax:323-299-9540
Practice Address - Street 1:3001 W VERNON AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008-5293
Practice Address - Country:US
Practice Address - Phone:323-299-9554
Practice Address - Fax:323-299-9540
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EGGLESTON YOUTH CENTERS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-09-09
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health