Provider Demographics
NPI:1801156831
Name:COASTAL MOUNTAIN YOUTH ACADEMY
Entity type:Organization
Organization Name:COASTAL MOUNTAIN YOUTH ACADEMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-498-7042
Mailing Address - Street 1:33171 PASEO CERVEZA
Mailing Address - Street 2:SUITE 120
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-4870
Mailing Address - Country:US
Mailing Address - Phone:949-498-7042
Mailing Address - Fax:949-248-2870
Practice Address - Street 1:33171 PASEO CERVEZA
Practice Address - Street 2:SUITE 120
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-4870
Practice Address - Country:US
Practice Address - Phone:949-498-7042
Practice Address - Fax:949-248-2870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-23
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchoolGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty