Healthcare Provider Details

I. General information

NPI: 1790575256
Provider Name (Legal Business Name): SOUTHEAST ALABAMA YOUTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2025
Last Update Date: 05/08/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2856 HORACE SHEPARD DR.
DOTHAN AL
36303
US

IV. Provider business mailing address

2856 HORACE SHEPARD DR.
DOTHAN AL
36303
US

V. Phone/Fax

Practice location:
  • Phone: 334-983-8377
  • Fax: 334-983-1289
Mailing address:
  • Phone: 334-983-8377
  • Fax: 334-983-1289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. TABITHA S BRANNON
Title or Position: EXECUTIVE DIRECTOR
Credential: LPC-S
Phone: 334-983-8377