Provider Demographics
NPI:1114937950
Name:CONCERNED CITIZENS FOR OUR YOUTH, INC.
Entity Type:Organization
Organization Name:CONCERNED CITIZENS FOR OUR YOUTH, INC.
Other - Org Name:BEACON HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-384-4539
Mailing Address - Street 1:PO BOX 852
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:AL
Mailing Address - Zip Code:35502-0852
Mailing Address - Country:US
Mailing Address - Phone:205-384-4539
Mailing Address - Fax:205-384-1496
Practice Address - Street 1:1200 BEACON LANE
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:AL
Practice Address - Zip Code:35504
Practice Address - Country:US
Practice Address - Phone:205-384-4539
Practice Address - Fax:205-384-1496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL000373322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
515-30702Medicare UPIN