Provider Demographics
NPI:1790575256
Name:SOUTHEAST ALABAMA YOUTH SERVICES
Entity type:Organization
Organization Name:SOUTHEAST ALABAMA YOUTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TABITHA
Authorized Official - Middle Name:S
Authorized Official - Last Name:BRANNON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC-S
Authorized Official - Phone:334-983-8377
Mailing Address - Street 1:2856 HORACE SHEPARD DR.
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303
Mailing Address - Country:US
Mailing Address - Phone:334-983-8377
Mailing Address - Fax:334-983-1289
Practice Address - Street 1:2856 HORACE SHEPARD DR.
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303
Practice Address - Country:US
Practice Address - Phone:334-983-8377
Practice Address - Fax:334-983-1289
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHEAST ALABAMA YOUTH SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-05-08
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL339100015Medicaid