Provider Demographics
NPI:1790067973
Name:CAROLINA YOUTH SERVICES
Entity Type:Organization
Organization Name:CAROLINA YOUTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:WITHERSPOON
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:843-452-0268
Mailing Address - Street 1:101 TEA OLIVE CT
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29485
Mailing Address - Country:US
Mailing Address - Phone:843-452-0268
Mailing Address - Fax:
Practice Address - Street 1:2150 SPOLATO LN E
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406
Practice Address - Country:US
Practice Address - Phone:843-452-0268
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-14
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLIC-5-11-62510101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty