Provider Demographics
NPI:1821725060
Name:INDEPENDENCE YOUTH CENTER
Entity Type:Organization
Organization Name:INDEPENDENCE YOUTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JANA
Authorized Official - Middle Name:
Authorized Official - Last Name:SANFORD-HELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-515-3735
Mailing Address - Street 1:14797 PHILIPS HWY STE 103
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-3746
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14797 PHILIPS HWY STE 103
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-3746
Practice Address - Country:US
Practice Address - Phone:904-515-3735
Practice Address - Fax:904-467-3422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-08
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty