Provider Demographics
NPI:1558959171
Name:YOUTH EVOLUTION TRACK LLC
Entity Type:Organization
Organization Name:YOUTH EVOLUTION TRACK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALISTS
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-373-4385
Mailing Address - Street 1:125 CLOVER POINT CIR
Mailing Address - Street 2:
Mailing Address - City:GUYTON
Mailing Address - State:GA
Mailing Address - Zip Code:31312-7134
Mailing Address - Country:US
Mailing Address - Phone:912-675-3421
Mailing Address - Fax:
Practice Address - Street 1:224 STEPHENSON AVE STE B
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-5921
Practice Address - Country:US
Practice Address - Phone:912-675-3421
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-08
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA124764OtherDRUG AND ALCOHOL