Provider Demographics
NPI:1407073588
Name:YOUTH HAVEN SERVICES, INC.
Entity Type:Organization
Organization Name:YOUTH HAVEN SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:TUCKER
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:336-349-2233
Mailing Address - Street 1:229 TURNER DR
Mailing Address - Street 2:
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27320-5736
Mailing Address - Country:US
Mailing Address - Phone:336-349-2233
Mailing Address - Fax:336-634-0444
Practice Address - Street 1:7921 US HIGHWAY 158
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-7606
Practice Address - Country:US
Practice Address - Phone:336-342-4026
Practice Address - Fax:336-634-0444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL079081251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8302064RMedicaid