Provider Demographics
NPI:1619217841
Name:HILLSIDES
Entity Type:Organization
Organization Name:HILLSIDES
Other - Org Name:HILLSIDES SUPPORT SERVICES CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:323-254-2274
Mailing Address - Street 1:815 COLORADO BLVD
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90041-1720
Mailing Address - Country:US
Mailing Address - Phone:323-543-2800
Mailing Address - Fax:
Practice Address - Street 1:815 COLORADO BLVD
Practice Address - Street 2:3RD FLOOR
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90041-1720
Practice Address - Country:US
Practice Address - Phone:323-543-2800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-25
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health