Basic Information
| Provider Information | |||||||||
| NPI: | 1932230620 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PENNY LANE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15317 RAYEN ST | ||||||||
| Address2: | |||||||||
| City: | NORTH HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913435117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188923423 | ||||||||
| FaxNumber: | 8188934509 | ||||||||
| Practice Location | |||||||||
| Address1: | 15317 RAYEN ST | ||||||||
| Address2: | |||||||||
| City: | NORTH HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913435117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188923423 | ||||||||
| FaxNumber: | 8188934509 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HOLTBY | ||||||||
| AuthorizedOfficialFirstName: | LYNNELL | ||||||||
| AuthorizedOfficialMiddleName: | JANE | ||||||||
| AuthorizedOfficialTitleorPosition: | RESIDENTIAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 8188923423 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | MFT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X | 41129 | CA | Y | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |
No ID Information.