Provider Demographics
NPI:1356448583
Name:VAN HORN YOUTH CENTER
Entity type:Organization
Organization Name:VAN HORN YOUTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:LILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-928-5568
Mailing Address - Street 1:22964 PABLO
Mailing Address - Street 2:
Mailing Address - City:NUEVO
Mailing Address - State:CA
Mailing Address - Zip Code:92567-9635
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22964 PABLO
Practice Address - Street 2:
Practice Address - City:NUEVO
Practice Address - State:CA
Practice Address - Zip Code:92567-9635
Practice Address - Country:US
Practice Address - Phone:951-928-5568
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW 20410320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness