Provider Demographics
NPI:1053540302
Name:YOUTH VILLAGES
Entity type:Organization
Organization Name:YOUTH VILLAGES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY COUNSELOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JUSTEN
Authorized Official - Middle Name:JON
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-403-4177
Mailing Address - Street 1:2428 CHARLES BLVD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-5924
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2428 CHARLES BLVD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-5924
Practice Address - Country:US
Practice Address - Phone:252-215-5708
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-08
Last Update Date:2009-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS. 0030847101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty