Provider Demographics
NPI:1093010456
Name:STEVEN INGRID BOONE YOUTH FOUNDATION
Entity Type:Organization
Organization Name:STEVEN INGRID BOONE YOUTH FOUNDATION
Other - Org Name:SIB YOUTH FOUNDATION
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TYKEYSHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOONE
Authorized Official - Suffix:
Authorized Official - Credentials:MPH, CHES
Authorized Official - Phone:205-410-5065
Mailing Address - Street 1:9721 PARKWAY E
Mailing Address - Street 2:SUITE A
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35215-7857
Mailing Address - Country:US
Mailing Address - Phone:205-410-2893
Mailing Address - Fax:
Practice Address - Street 1:459 MAIN ST
Practice Address - Street 2:SUITE 101-273
Practice Address - City:TRUSSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35173-1416
Practice Address - Country:US
Practice Address - Phone:205-853-3526
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-17
Last Update Date:2011-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251300000XAgenciesLocal Education Agency (LEA)
No251B00000XAgenciesCase Management
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251K00000XAgenciesPublic Health or Welfare
No251V00000XAgenciesVoluntary or Charitable
No252Y00000XAgenciesEarly Intervention Provider Agency