Provider Demographics
NPI:1831377506
Name:THE CAROLYN E.WYLIE CENTER FOR CHILDREN, YOUTH & FAMILIES
Entity type:Organization
Organization Name:THE CAROLYN E.WYLIE CENTER FOR CHILDREN, YOUTH & FAMILIES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:G
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:951-683-5193
Mailing Address - Street 1:4164 BROCKTON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-3400
Mailing Address - Country:US
Mailing Address - Phone:951-683-5193
Mailing Address - Fax:951-683-6019
Practice Address - Street 1:4164 BROCKTON AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-3400
Practice Address - Country:US
Practice Address - Phone:951-683-5193
Practice Address - Fax:951-683-6019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-05
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3345Medicaid