Provider Demographics
NPI:1073755583
Name:ALEXANDER YOUTH NETWORK
Entity Type:Organization
Organization Name:ALEXANDER YOUTH NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MISS
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:BASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-366-8712
Mailing Address - Street 1:6220 THERMAL RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-5630
Mailing Address - Country:US
Mailing Address - Phone:704-366-8712
Mailing Address - Fax:704-362-8464
Practice Address - Street 1:6220 THERMAL RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-5630
Practice Address - Country:US
Practice Address - Phone:704-366-8712
Practice Address - Fax:704-362-8464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-30
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-060-059323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3404503Medicaid