Provider Demographics
NPI:1245759612
Name:CAROLINA YOUTH ASSOCIATION
Entity Type:Organization
Organization Name:CAROLINA YOUTH ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:TAWANDA
Authorized Official - Middle Name:LANELLE
Authorized Official - Last Name:DUNCAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-780-3047
Mailing Address - Street 1:1801 N TRYON ST STE 350
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28206-2789
Mailing Address - Country:US
Mailing Address - Phone:704-967-9913
Mailing Address - Fax:
Practice Address - Street 1:1801 N TRYON ST STE 350
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28206-2789
Practice Address - Country:US
Practice Address - Phone:704-967-9913
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAROLINA YOUTH ASSOCIATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-09-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8470783OtherIDENTIFICATION