Provider Demographics
NPI:1861658536
Name:TEEN SUCCESS, LLC
Entity Type:Organization
Organization Name:TEEN SUCCESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORGANIZER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:MOATS
Authorized Official - Suffix:
Authorized Official - Credentials:LBSW
Authorized Official - Phone:515-971-7605
Mailing Address - Street 1:408 5TH ST NW
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:IA
Mailing Address - Zip Code:50009-1427
Mailing Address - Country:US
Mailing Address - Phone:515-971-7605
Mailing Address - Fax:
Practice Address - Street 1:408 5TH ST NW
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:IA
Practice Address - Zip Code:50009-1427
Practice Address - Country:US
Practice Address - Phone:515-971-7605
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-01
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA04652251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health