Provider Demographics
NPI:1780782508
Name:NORTHSTAR YOUTH ACADEMY LLC
Entity type:Organization
Organization Name:NORTHSTAR YOUTH ACADEMY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:BANKS
Authorized Official - Middle Name:
Authorized Official - Last Name:BOURGEOUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-369-4466
Mailing Address - Street 1:920 COLUMBIA LN
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-1320
Mailing Address - Country:US
Mailing Address - Phone:801-369-4466
Mailing Address - Fax:
Practice Address - Street 1:900 COLUMBIA LN
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-1320
Practice Address - Country:US
Practice Address - Phone:801-787-6194
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT119323245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children