Basic Information
Provider Information | |||||||||
NPI: | 1841453438 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | YOUTH FOR CHANGE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HOMELESS-RUNAWAY EMERGENCY ACTION RESPONSE TEAM | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1476 | ||||||||
Address2: |   | ||||||||
City: | PARADISE | ||||||||
State: | CA | ||||||||
PostalCode: | 959671476 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5308778187 | ||||||||
FaxNumber: | 5308945791 | ||||||||
Practice Location | |||||||||
Address1: | 572 RIO LINDO AVE STE 104B&D | ||||||||
Address2: |   | ||||||||
City: | CHICO | ||||||||
State: | CA | ||||||||
PostalCode: | 95926 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5308774786 | ||||||||
FaxNumber: | 5308945791 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/03/2008 | ||||||||
LastUpdateDate: | 05/14/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KELLY | ||||||||
AuthorizedOfficialFirstName: | ROSEMARY | ||||||||
AuthorizedOfficialMiddleName: | LISA | ||||||||
AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
AuthorizedOfficialTelephone: | 5308945933 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
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.