Provider Demographics
NPI:1477895985
Name:EDIFY YOUTH
Entity Type:Organization
Organization Name:EDIFY YOUTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:BAUER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-567-3136
Mailing Address - Street 1:5108 LAKESIDE AVE N
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55429-3734
Mailing Address - Country:US
Mailing Address - Phone:612-306-4575
Mailing Address - Fax:763-271-2707
Practice Address - Street 1:5108 LAKESIDE AVE N
Practice Address - Street 2:
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55429-3734
Practice Address - Country:US
Practice Address - Phone:612-306-4575
Practice Address - Fax:763-271-2707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-22
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty