Provider Demographics
NPI:1780762989
Name:CANYON LAKES RESIDENTIAL TREATMENT CENTER
Entity type:Organization
Organization Name:CANYON LAKES RESIDENTIAL TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LENISE
Authorized Official - Middle Name:L
Authorized Official - Last Name:STAHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-762-5782
Mailing Address - Street 1:2402 CANYON LAKES DR
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79415-2000
Mailing Address - Country:US
Mailing Address - Phone:806-762-5782
Mailing Address - Fax:806-762-0838
Practice Address - Street 1:2402 CANYON LAKES DR
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79415-2000
Practice Address - Country:US
Practice Address - Phone:806-762-5782
Practice Address - Fax:806-762-0838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children