Provider Demographics
NPI:1457404709
Name:YOUTHFUL IMAGE INC
Entity Type:Organization
Organization Name:YOUTHFUL IMAGE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:LAMONT
Authorized Official - Last Name:SEAGRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-209-5122
Mailing Address - Street 1:853 BLAZINGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-8228
Mailing Address - Country:US
Mailing Address - Phone:336-209-5122
Mailing Address - Fax:336-638-9400
Practice Address - Street 1:912 ASHE ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27406-1204
Practice Address - Country:US
Practice Address - Phone:336-691-5748
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC041746101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603915Medicaid