Basic Information
Provider Information | |||||||||
NPI: | 1598982670 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | YOUTH HAVEN SERVICES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 229 TURNER DR | ||||||||
Address2: |   | ||||||||
City: | REIDSVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 273205736 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3363492233 | ||||||||
FaxNumber: | 3366340444 | ||||||||
Practice Location | |||||||||
Address1: | 229 TURNER DR | ||||||||
Address2: |   | ||||||||
City: | REIDSVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 273205736 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3363492233 | ||||||||
FaxNumber: | 3366340444 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/19/2007 | ||||||||
LastUpdateDate: | 05/24/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JOHNSON | ||||||||
AuthorizedOfficialFirstName: | DAWN | ||||||||
AuthorizedOfficialMiddleName: | TUCKER | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 3363492233 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LCSW | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X |   |   | Y |   | Agencies | Case Management |   |
ID Information
ID | Type | State | Issuer | Description | 8300811B | 05 | NC |   | MEDICAID |