Provider Demographics
NPI:1669086013
Name:YOUR LIFE SERVICE LEAGUE LICENSED CLINICAL SOCIAL WORKER APC
Entity type:Organization
Organization Name:YOUR LIFE SERVICE LEAGUE LICENSED CLINICAL SOCIAL WORKER APC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:LANDON
Authorized Official - Middle Name:DERRICK
Authorized Official - Last Name:HALLBROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:951-850-1574
Mailing Address - Street 1:300 S PARK AVE STE 820
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-1501
Mailing Address - Country:US
Mailing Address - Phone:951-850-1574
Mailing Address - Fax:
Practice Address - Street 1:435 W MISSION BLVD STE 301
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766-1632
Practice Address - Country:US
Practice Address - Phone:951-850-1574
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-03
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty