Provider Demographics
NPI:1366486680
Name:TEEN CHALLENGE OF FLORIDA, INC.
Entity Type:Organization
Organization Name:TEEN CHALLENGE OF FLORIDA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRICE
Authorized Official - Middle Name:
Authorized Official - Last Name:MADDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-596-8731
Mailing Address - Street 1:15 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901-2744
Mailing Address - Country:US
Mailing Address - Phone:706-596-8731
Mailing Address - Fax:706-596-8732
Practice Address - Street 1:25 W WEBSTER ST
Practice Address - Street 2:
Practice Address - City:SEBREE
Practice Address - State:KY
Practice Address - Zip Code:42455
Practice Address - Country:US
Practice Address - Phone:484-868-0584
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X, 251S00000X, 261QM0850X
FL0759AD922801324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilityGroup - Multi-Specialty