Provider Demographics
NPI:1194857318
Name:MIDWAY YOUTH SERVICES, INC
Entity Type:Organization
Organization Name:MIDWAY YOUTH SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BARBRA
Authorized Official - Middle Name:RACHELLE
Authorized Official - Last Name:MONTOYA
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC
Authorized Official - Phone:970-484-7447
Mailing Address - Street 1:729 REMINGTON ST
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-3332
Mailing Address - Country:US
Mailing Address - Phone:970-484-7447
Mailing Address - Fax:
Practice Address - Street 1:1516 REMINGTON ST
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-4140
Practice Address - Country:US
Practice Address - Phone:970-484-7447
Practice Address - Fax:970-484-7471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO44002322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO67458297Medicaid