Provider Demographics
NPI:1093998213
Name:YOUTH VILLAGES
Entity Type:Organization
Organization Name:YOUTH VILLAGES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:VONDA
Authorized Official - Middle Name:KARLA
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:423-283-6517
Mailing Address - Street 1:3915 BRISTOL HWY
Mailing Address - Street 2:SUITE 202
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-1400
Mailing Address - Country:US
Mailing Address - Phone:423-283-6500
Mailing Address - Fax:
Practice Address - Street 1:3915 BRISTOL HWY
Practice Address - Street 2:SUITE 202
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-1400
Practice Address - Country:US
Practice Address - Phone:423-283-6500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health