Provider Demographics
NPI:1083832117
Name:MOUNTAIN YOUTH ACADEMY
Entity Type:Organization
Organization Name:MOUNTAIN YOUTH ACADEMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MISS
Authorized Official - First Name:CLARA
Authorized Official - Middle Name:E
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:423-727-9898
Mailing Address - Street 1:332 HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37683-4309
Mailing Address - Country:US
Mailing Address - Phone:423-727-9898
Mailing Address - Fax:423-727-9899
Practice Address - Street 1:332 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN CITY
Practice Address - State:TN
Practice Address - Zip Code:37683-4309
Practice Address - Country:US
Practice Address - Phone:423-727-9898
Practice Address - Fax:423-727-9899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNL237M21261695320600000X, 322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Not Answered322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children