Provider Demographics
NPI:1558475319
Name:LEE COUNTY YOUTH DEVELOPMENT CENTER
Entity Type:Organization
Organization Name:LEE COUNTY YOUTH DEVELOPMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:J
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:334-749-2996
Mailing Address - Street 1:1109 SPRING DR
Mailing Address - Street 2:
Mailing Address - City:OPELIKA
Mailing Address - State:AL
Mailing Address - Zip Code:36801-5345
Mailing Address - Country:US
Mailing Address - Phone:334-749-2996
Mailing Address - Fax:334-745-0503
Practice Address - Street 1:1109 SPRING DR
Practice Address - Street 2:
Practice Address - City:OPELIKA
Practice Address - State:AL
Practice Address - Zip Code:36801-5345
Practice Address - Country:US
Practice Address - Phone:334-749-2996
Practice Address - Fax:334-745-0503
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEE COUNTY YOUTH DEVELOPMENT CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-18
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL263 & 9425322D00000X
323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL339100001Medicaid