Provider Demographics
NPI:1982854360
Name:INNERCHANGE YOUTH HOMES LLC
Entity Type:Organization
Organization Name:INNERCHANGE YOUTH HOMES LLC
Other - Org Name:INNERCHANGE YOUTH DIVISION 1
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DINA
Authorized Official - Middle Name:CATRESS
Authorized Official - Last Name:SAWYER
Authorized Official - Suffix:
Authorized Official - Credentials:B/S IN CRIMINAL JUST
Authorized Official - Phone:704-458-1356
Mailing Address - Street 1:P.O. BOX 36448
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28236-6448
Mailing Address - Country:US
Mailing Address - Phone:704-884-0096
Mailing Address - Fax:704-884-0097
Practice Address - Street 1:724 RAINDROPS RD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-1779
Practice Address - Country:US
Practice Address - Phone:704-884-0096
Practice Address - Fax:704-884-0097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-23
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL036260322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children