Provider Demographics
NPI:1639231194
Name:FAVOR YOUTH SERVICES, INC.
Entity Type:Organization
Organization Name:FAVOR YOUTH SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:TRAMALLE
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:QMHP
Authorized Official - Phone:704-866-9177
Mailing Address - Street 1:1568 UNION RD STE A
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-2211
Mailing Address - Country:US
Mailing Address - Phone:704-866-9177
Mailing Address - Fax:704-866-9176
Practice Address - Street 1:1568 UNION RD STE A
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2211
Practice Address - Country:US
Practice Address - Phone:704-866-9177
Practice Address - Fax:704-866-9176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC251B00000X251B00000X
NC251C00000X251C00000X
NC251S00000X251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3418155OtherCAP NUMBER
NC8300200BMedicaid