Provider Demographics
NPI:1306211826
Name:SOUTHLAND MARRIAGE AND FAMILY
Entity Type:Organization
Organization Name:SOUTHLAND MARRIAGE AND FAMILY
Other - Org Name:SOUTHLAND MENTAL HEALTH ALLIANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:PRYSTASH
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:951-526-4118
Mailing Address - Street 1:28364 VINCENT MORAGA DR
Mailing Address - Street 2:F
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590-3656
Mailing Address - Country:US
Mailing Address - Phone:951-526-4118
Mailing Address - Fax:951-602-6166
Practice Address - Street 1:28364 VINCENT MORAGA DR
Practice Address - Street 2:F
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-3656
Practice Address - Country:US
Practice Address - Phone:951-526-4118
Practice Address - Fax:951-602-6166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-09
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC24093251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health