Provider Demographics
NPI:1700024098
Name:BRANDON J INC/SERENITY PLACE
Entity Type:Organization
Organization Name:BRANDON J INC/SERENITY PLACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LOURDES
Authorized Official - Middle Name:A
Authorized Official - Last Name:LEFEVRE
Authorized Official - Suffix:
Authorized Official - Credentials:CERTIFICATE
Authorized Official - Phone:909-430-0922
Mailing Address - Street 1:128 E. G ST. #111
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324
Mailing Address - Country:US
Mailing Address - Phone:909-430-0922
Mailing Address - Fax:909-430-0923
Practice Address - Street 1:128 E G ST STE 111
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-2943
Practice Address - Country:US
Practice Address - Phone:909-430-0922
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-26
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA368607101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty