MEDICARE: ECKERD YOUTH ALTERNATIVES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist
2	323P00000X	Psychiatric Residential Treatment Facility

General Provider Information

NPI Number	:	1336218486
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ECKERD YOUTH ALTERNATIVES

Provider Business Mailing Address
First Line	:	100 STARCREST DR
Second Line	:
City	:	CLEARWATER
State	:	FL
Zip	:	33765-3224
Country	:	US
Telephone Number	:	727-461-2990
Fax Number	:	727-216-0055

Provider Business Practice Location Address
First Line	:	4654 HIGH ROCK RD
Second Line	:
City	:	BOOMER
State	:	NC
Zip	:	28606-9109
Country	:	US
Telephone Number	:	336-921-3300
Fax Number	:	336-921-4320

Authorized Official
Title or Position	:	CONTROLLER
Name	:	NICOLE STROEBEL
Credential	:
Telephone Number	:	727-461-2990

Provider Enumeration Date	:	11/06/2006
Last Update Date	:	11/20/2019

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