Provider Demographics
NPI:1609010842
Name:ALEXANDER YOUTH NETWORK
Entity Type:Organization
Organization Name:ALEXANDER YOUTH NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:BASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-366-8712
Mailing Address - Street 1:PO BOX 220632
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28222-0632
Mailing Address - Country:US
Mailing Address - Phone:704-366-8712
Mailing Address - Fax:704-362-8464
Practice Address - Street 1:5855 EXECUTIVE CENTER DR
Practice Address - Street 2:SUITE 105
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-8883
Practice Address - Country:US
Practice Address - Phone:704-537-1202
Practice Address - Fax:704-537-1209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-30
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300243BMedicaid
NC8300243GMedicaid
NC8300243HMedicaid
NC8300243IMedicaid
NC8300243Medicaid