Provider Demographics
NPI:1467713743
Name:LEROY HAYNES CENTER
Entity Type:Organization
Organization Name:LEROY HAYNES CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHIATRIC TECHNICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-592-3281
Mailing Address - Street 1:233 BASELINE RD
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-2353
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:233 BASELINE RD
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-2353
Practice Address - Country:US
Practice Address - Phone:909-593-2581
Practice Address - Fax:909-596-3567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-04
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 34218322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7565AOtherOUTPATIENT MENTAL HEALTH