Provider Demographics
NPI:1235400490
Name:FAMILY YOUTH ROUNDTABLE OF SAN DIEGO COUNTY
Entity Type:Organization
Organization Name:FAMILY YOUTH ROUNDTABLE OF SAN DIEGO COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:EWING
Authorized Official - Last Name:MARTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-546-5852
Mailing Address - Street 1:345 15TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-8951
Mailing Address - Country:US
Mailing Address - Phone:619-546-5852
Mailing Address - Fax:619-546-6251
Practice Address - Street 1:345 15TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-8951
Practice Address - Country:US
Practice Address - Phone:619-546-5852
Practice Address - Fax:619-546-6251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X, 251K00000X, 251S00000X, 252Y00000X
CA45174251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No251K00000XAgenciesPublic Health or Welfare
No252Y00000XAgenciesEarly Intervention Provider Agency