Provider Demographics
NPI:1336333558
Name:PRO KIDS YOUTH AND FAMILY SERVICE
Entity Type:Organization
Organization Name:PRO KIDS YOUTH AND FAMILY SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DEMISE
Authorized Official - Middle Name:LAMAAR
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-674-5455
Mailing Address - Street 1:2559 QUAIL RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28056-9205
Mailing Address - Country:US
Mailing Address - Phone:704-674-5455
Mailing Address - Fax:
Practice Address - Street 1:2559 QUAIL RIDGE DR
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28056-9205
Practice Address - Country:US
Practice Address - Phone:704-674-5455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-30
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC251B00000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health