Provider Demographics
NPI:1265751762
Name:ST JOHNS YOUTH ACADEMY
Entity type:Organization
Organization Name:ST JOHNS YOUTH ACADEMY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:BARIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAYSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:904-829-8850
Mailing Address - Street 1:4500 AVENUE D
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32095-5245
Mailing Address - Country:US
Mailing Address - Phone:904-829-8850
Mailing Address - Fax:904-829-8851
Practice Address - Street 1:4500 AVENUE D
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32095-5245
Practice Address - Country:US
Practice Address - Phone:904-829-8850
Practice Address - Fax:904-829-8851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-24
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0755AD5690-093245S0500X
322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0755AD5690-09OtherSUBSTANCE ABUSE LICENSE