Provider Demographics
NPI:1417131210
Name:YOUTH IMAGE, INC.
Entity Type:Organization
Organization Name:YOUTH IMAGE, INC.
Other - Org Name:N/A
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:COLLETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-433-4485
Mailing Address - Street 1:PO BOX 914
Mailing Address - Street 2:
Mailing Address - City:MORGANTON
Mailing Address - State:NC
Mailing Address - Zip Code:28680-0914
Mailing Address - Country:US
Mailing Address - Phone:828-433-4485
Mailing Address - Fax:828-433-4486
Practice Address - Street 1:107 KELA DR
Practice Address - Street 2:
Practice Address - City:MORGANTON
Practice Address - State:NC
Practice Address - Zip Code:28655-7868
Practice Address - Country:US
Practice Address - Phone:828-439-1705
Practice Address - Fax:828-433-4486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-28
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL 012-111322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children