Provider Demographics
NPI:1518407519
Name:FORGET ME KNOT YOUTH SERVICES
Entity Type:Organization
Organization Name:FORGET ME KNOT YOUTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:QUINZELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BETHEA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-758-1153
Mailing Address - Street 1:2321 N BROAD STREET
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19132
Mailing Address - Country:US
Mailing Address - Phone:215-758-1153
Mailing Address - Fax:
Practice Address - Street 1:2321 N BROAD STREET
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19132
Practice Address - Country:US
Practice Address - Phone:215-758-1153
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-24
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children