Provider Demographics
NPI:1235272717
Name:SUPPORTED LIVING YOUTH, FAMILY & CHILDREN SERVICES, INC.
Entity Type:Organization
Organization Name:SUPPORTED LIVING YOUTH, FAMILY & CHILDREN SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:HILLIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-283-6002
Mailing Address - Street 1:PO BOX 3398
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28111-3398
Mailing Address - Country:US
Mailing Address - Phone:704-283-6002
Mailing Address - Fax:704-225-1582
Practice Address - Street 1:717 WHITE OAKS CIRCLE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-7014
Practice Address - Country:US
Practice Address - Phone:704-283-6002
Practice Address - Fax:704-225-1582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL090141101Y00000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603459Medicaid