Provider Demographics
NPI:1609233410
Name:ADULT YOUTH SERVICES
Entity Type:Organization
Organization Name:ADULT YOUTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:GUPTON-JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:719-442-1779
Mailing Address - Street 1:223 N WAHSATCH AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-3479
Mailing Address - Country:US
Mailing Address - Phone:719-442-1779
Mailing Address - Fax:719-442-0538
Practice Address - Street 1:223 N WAHSATCH AVE
Practice Address - Street 2:STE 101
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-3479
Practice Address - Country:US
Practice Address - Phone:719-442-1779
Practice Address - Fax:719-442-0538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-25
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty