Provider Demographics
NPI:1750407250
Name:YOUTH180, INC.
Entity type:Organization
Organization Name:YOUTH180, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT-CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:KERI
Authorized Official - Middle Name:
Authorized Official - Last Name:STITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-746-6381
Mailing Address - Street 1:7777 FOREST LN
Mailing Address - Street 2:SUITE C-410
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-2571
Mailing Address - Country:US
Mailing Address - Phone:972-566-4680
Mailing Address - Fax:972-566-6378
Practice Address - Street 1:201 S TYLER ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-4934
Practice Address - Country:US
Practice Address - Phone:214-942-5166
Practice Address - Fax:214-942-6006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2426-2426A261QR0405X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1750407250Medicaid