Provider Demographics
NPI:1578991709
Name:KLAMATH YOUTH DEVELOPMENT CENTER
Entity Type:Organization
Organization Name:KLAMATH YOUTH DEVELOPMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREATMENT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:HANNA
Authorized Official - Last Name:WALDRON
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:541-883-1030
Mailing Address - Street 1:1527 LOOKOUT AVE
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601
Mailing Address - Country:US
Mailing Address - Phone:541-892-2221
Mailing Address - Fax:
Practice Address - Street 1:2210 N ELDORADO AVE
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601
Practice Address - Country:US
Practice Address - Phone:541-883-1030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-25
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR223354Medicaid