MEDICARE: INSPIRATIONS YOUTH ACADEMY LLC

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	261QM0855X	Adolescent and Children Mental Health Clinic/Center

General Provider Information

NPI Number	:	1821595281
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INSPIRATIONS YOUTH ACADEMY LLC

Provider Business Mailing Address
First Line	:	757 SOUTH EAST 17TH STREET
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33316-2960
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	757 SOUTH EAST 17TH STREET
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33316-2960
Country	:	US
Telephone Number	:	800-868-8772
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	CHRIS WALSH
Credential	:	LPN
Telephone Number	:	954-376-4783

Provider Enumeration Date	:	04/11/2018
Last Update Date	:	04/11/2018

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