Provider Demographics
NPI:1770008153
Name:EMMAUS ROAD CHRISTIAN COUNSELING
Entity Type:Organization
Organization Name:EMMAUS ROAD CHRISTIAN COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-979-3722
Mailing Address - Street 1:1111 W COVINA BLVD STE 120A
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-3205
Mailing Address - Country:US
Mailing Address - Phone:1909-979-3722
Mailing Address - Fax:
Practice Address - Street 1:1111 W COVINA BLVD STE 120A
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-3205
Practice Address - Country:US
Practice Address - Phone:1909-979-3722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-07
Last Update Date:2017-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty