Basic Information
| Provider Information | |||||||||
| NPI: | 1184124539 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | YOUTH FOR CHANGE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MARYSVILLE YFC SUPPORT CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1128 YUBA ST | ||||||||
| Address2: | |||||||||
| City: | MARYSVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959014831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5304181001 | ||||||||
| FaxNumber: | 5304181005 | ||||||||
| Practice Location | |||||||||
| Address1: | 1128 YUBA ST | ||||||||
| Address2: | |||||||||
| City: | MARYSVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959014831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5304181001 | ||||||||
| FaxNumber: | 5304181005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2018 | ||||||||
| LastUpdateDate: | 02/12/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KELLY | ||||||||
| AuthorizedOfficialFirstName: | ROSEMARY | ||||||||
| AuthorizedOfficialMiddleName: | LISA | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED NPI OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 5308945933 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
No ID Information.