Provider Demographics
NPI:1245787324
Name:SEQUEL YOUTH SERVICES OF LAVA HEIGHTS
Entity type:Organization
Organization Name:SEQUEL YOUTH SERVICES OF LAVA HEIGHTS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF PROGRAM OFFICER/EVP
Authorized Official - Prefix:MRS
Authorized Official - First Name:MANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-880-3339
Mailing Address - Street 1:1131 EAGLETREE LN SW
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-6491
Mailing Address - Country:US
Mailing Address - Phone:256-880-3339
Mailing Address - Fax:256-880-7026
Practice Address - Street 1:730 E. SPRING DRIVE
Practice Address - Street 2:
Practice Address - City:TOQUERVILLE
Practice Address - State:UT
Practice Address - Zip Code:84774
Practice Address - Country:US
Practice Address - Phone:435-645-0300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CARE YOUTH CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-09-06
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility