Provider Demographics
NPI:1023171758
Name:YOUTH PROFILE INC.
Entity type:Organization
Organization Name:YOUTH PROFILE INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSO. EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ALFRED
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MCBRIDE
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:336-707-0377
Mailing Address - Street 1:5683 GREENDALE CT
Mailing Address - Street 2:
Mailing Address - City:SUMMERFIELD
Mailing Address - State:NC
Mailing Address - Zip Code:27358-9156
Mailing Address - Country:US
Mailing Address - Phone:336-707-0377
Mailing Address - Fax:336-644-1423
Practice Address - Street 1:4010 COLTRAIN RD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27455-2632
Practice Address - Country:US
Practice Address - Phone:336-545-1612
Practice Address - Fax:336-644-1423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-16
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-041-204322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603100Medicaid