Provider Demographics
NPI:1932333846
Name:CANYON LAKES RTC
Entity type:Organization
Organization Name:CANYON LAKES RTC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:STAHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-762-5782
Mailing Address - Street 1:2402 CANYON LAKE DR
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79415-2000
Mailing Address - Country:US
Mailing Address - Phone:806-762-5782
Mailing Address - Fax:
Practice Address - Street 1:2402 CANYON LAKE DR
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79415-2000
Practice Address - Country:US
Practice Address - Phone:806-762-5782
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-06
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX64653101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty