Healthcare Provider Details

I. General information

NPI: 1558475319
Provider Name (Legal Business Name): LEE COUNTY YOUTH DEVELOPMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 08/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1109 SPRING DR
OPELIKA AL
36801-5345
US

IV. Provider business mailing address

1109 SPRING DR
OPELIKA AL
36801-5345
US

V. Phone/Fax

Practice location:
  • Phone: 334-749-2996
  • Fax: 334-745-0503
Mailing address:
  • Phone: 334-749-2996
  • Fax: 334-745-0503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number263 & 9425
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. LAURA J COOPER
Title or Position: EXECUTIVE DIRECTOR
Credential: M.ED.
Phone: 334-749-2996