Provider Demographics
NPI:1407100027
Name:CROSSWINDS YOUTH SERVICES
Entity Type:Organization
Organization Name:CROSSWINDS YOUTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:D
Authorized Official - Last Name:LOCKE
Authorized Official - Suffix:
Authorized Official - Credentials:MPA
Authorized Official - Phone:321-452-0800
Mailing Address - Street 1:1407 DIXON BLVD
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32922-6411
Mailing Address - Country:US
Mailing Address - Phone:321-452-0800
Mailing Address - Fax:
Practice Address - Street 1:1407 DIXON BLVD
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32922
Practice Address - Country:US
Practice Address - Phone:321-452-0800
Practice Address - Fax:321-452-0800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-05
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL075153700Medicaid