Provider Demographics
NPI:1760100804
Name:SOUTHEAST ALABAMA YOUTH SERVICES, INC
Entity Type:Organization
Organization Name:SOUTHEAST ALABAMA YOUTH SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:DANIELLE
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-983-8377
Mailing Address - Street 1:2856 HORACE SHEPARD DR
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303-1007
Mailing Address - Country:US
Mailing Address - Phone:334-714-2549
Mailing Address - Fax:334-983-1289
Practice Address - Street 1:76 VICTORIA ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:AL
Practice Address - Zip Code:36048-3525
Practice Address - Country:US
Practice Address - Phone:334-714-2549
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-15
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty