Provider Demographics
NPI:1639613821
Name:HILLSIDES
Entity Type:Organization
Organization Name:HILLSIDES
Other - Org Name:HILLSIDES OUTPATIENT
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT/CEO
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 1:940 AVENUE 64
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-2711
Mailing Address - Country:US
Mailing Address - Phone:323-254-2274
Mailing Address - Fax:
Practice Address - Street 1:940 AVENUE 64
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2711
Practice Address - Country:US
Practice Address - Phone:323-254-2274
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HILLSIDES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-12-07
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)