Provider Demographics
NPI:1164417465
Name:CASSANDRA WOODRUFF YOUTH CENTER
Entity Type:Organization
Organization Name:CASSANDRA WOODRUFF YOUTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODRUFF
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:423-493-1867
Mailing Address - Street 1:2711 BENTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37406-3621
Mailing Address - Country:US
Mailing Address - Phone:423-493-1867
Mailing Address - Fax:
Practice Address - Street 1:605 HEMPHILL CIR
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37411-2912
Practice Address - Country:US
Practice Address - Phone:423-698-0229
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNSO/CO286322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children