Provider Demographics
NPI:1073562211
Name:THE YOUTH ACADEMY, INC.
Entity Type:Organization
Organization Name:THE YOUTH ACADEMY, INC.
Other - Org Name:THE YOUTH ACADEMY GROUP HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR / LCS
Authorized Official - Prefix:MS
Authorized Official - First Name:DAPHNE
Authorized Official - Middle Name:WILSON
Authorized Official - Last Name:BOSTON
Authorized Official - Suffix:
Authorized Official - Credentials:LCS
Authorized Official - Phone:843-382-5927
Mailing Address - Street 1:237 LELA HARRISON RD
Mailing Address - Street 2:PO BOX 174
Mailing Address - City:KINGSTREE
Mailing Address - State:SC
Mailing Address - Zip Code:29556-6771
Mailing Address - Country:US
Mailing Address - Phone:843-382-5927
Mailing Address - Fax:843-382-5826
Practice Address - Street 1:237 LELA HARRISON RD
Practice Address - Street 2:
Practice Address - City:KINGSTREE
Practice Address - State:SC
Practice Address - Zip Code:29556-6771
Practice Address - Country:US
Practice Address - Phone:843-382-5927
Practice Address - Fax:843-382-5826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSR-0001723001-GH101YP2500X
SCSR-0008158001-CCI101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC944MXHMedicare UPIN