Provider Demographics
NPI:1841429669
Name:CHABAD RESIDENTIAL TREATMENT CENTER
Entity Type:Organization
Organization Name:CHABAD RESIDENTIAL TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:MFT
Authorized Official - Phone:323-965-1365
Mailing Address - Street 1:5675 W OLYMPIC BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-4712
Mailing Address - Country:US
Mailing Address - Phone:323-965-1365
Mailing Address - Fax:323-965-0444
Practice Address - Street 1:5675 W OLYMPIC BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-4712
Practice Address - Country:US
Practice Address - Phone:323-965-1365
Practice Address - Fax:323-965-0444
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHABAD OF CALIFORNIA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-14
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA190087CN324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility