Provider Demographics
NPI:1699821165
Name:SEACOAST YOUTH ACADEMY
Entity Type:Organization
Organization Name:SEACOAST YOUTH ACADEMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:
Authorized Official - First Name:SHERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-340-0701
Mailing Address - Street 1:6367 BAY RD
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588-6501
Mailing Address - Country:US
Mailing Address - Phone:843-215-8080
Mailing Address - Fax:
Practice Address - Street 1:6367 BAY RD
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-6501
Practice Address - Country:US
Practice Address - Phone:843-215-8080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children