Provider Demographics
NPI:1639515018
Name:KLAMATH YOUTH DEVELOPMENT CENTER
Entity Type:Organization
Organization Name:KLAMATH YOUTH DEVELOPMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SKILLS BUILDER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:DANIELLE
Authorized Official - Last Name:PFEFFEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-526-8311
Mailing Address - Street 1:531 N 8TH ST
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-2908
Mailing Address - Country:US
Mailing Address - Phone:530-526-8311
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:97601-6418
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:2013-05-13
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health