Provider Demographics
NPI:1629099890
Name:MARION YOUTH DEVELOPMENT CENTER
Entity Type:Organization
Organization Name:MARION YOUTH DEVELOPMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:352-671-2777
Mailing Address - Street 1:4055 NW 105TH ST
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34482-1434
Mailing Address - Country:US
Mailing Address - Phone:352-671-2777
Mailing Address - Fax:352-368-5940
Practice Address - Street 1:4055 NW 105TH ST
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34482-1434
Practice Address - Country:US
Practice Address - Phone:352-671-2777
Practice Address - Fax:352-368-5940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
322D00000X
FL1342AD56903245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Not Answered3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children