Healthcare Provider Details

I. General information

NPI: 1093010456
Provider Name (Legal Business Name): STEVEN INGRID BOONE YOUTH FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2011
Last Update Date: 01/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

459 MAIN ST SUITE 101-273
TRUSSVILLE AL
35173-1416
US

IV. Provider business mailing address

9721 PARKWAY E SUITE A
BIRMINGHAM AL
35215-7857
US

V. Phone/Fax

Practice location:
  • Phone: 205-853-3526
  • Fax:
Mailing address:
  • Phone: 205-410-2893
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. TYKEYSHA BOONE
Title or Position: ADMINISTRATIVE DIRECTOR
Credential: MPH, CHES
Phone: 205-410-5065