Provider Demographics
NPI:1811022718
Name:FRESH START YOUTH SERVICES, INC.
Entity Type:Organization
Organization Name:FRESH START YOUTH SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:EDMOND
Authorized Official - Last Name:LHEUREUX
Authorized Official - Suffix:
Authorized Official - Credentials:MA, MPA
Authorized Official - Phone:704-226-2469
Mailing Address - Street 1:2110 GRIFFITH RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28112-8833
Mailing Address - Country:US
Mailing Address - Phone:704-282-4243
Mailing Address - Fax:704-218-6743
Practice Address - Street 1:2110 GRIFFITH RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-8833
Practice Address - Country:US
Practice Address - Phone:704-282-4243
Practice Address - Fax:704-218-6743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC090143322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603451Medicaid