Provider Demographics
NPI:1003279613
Name:LEE COUNTY YOUTH DEVELOPMENT CENTER
Entity Type:Organization
Organization Name:LEE COUNTY YOUTH DEVELOPMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-749-2996
Mailing Address - Street 1:1109 SPRING DR
Mailing Address - Street 2:
Mailing Address - City:OPELIKA
Mailing Address - State:AL
Mailing Address - Zip Code:36801-5345
Mailing Address - Country:US
Mailing Address - Phone:334-749-2996
Mailing Address - Fax:
Practice Address - Street 1:1109 SPRING DR
Practice Address - Street 2:
Practice Address - City:OPELIKA
Practice Address - State:AL
Practice Address - Zip Code:36801-5345
Practice Address - Country:US
Practice Address - Phone:334-749-2996
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-31
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL671261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1861631962OtherNPPES
ALRTF0001HMedicaid
1336396399OtherNPPES
1407003486OtherNPPES
1558475319OtherNPPES
1427295591OtherNPPES
AL339100001Medicaid
1619368875OtherNPPES
AL339090245Medicaid
AL529804070Medicaid