Healthcare Provider Details

I. General information

NPI: 1841453438
Provider Name (Legal Business Name): YOUTH FOR CHANGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2008
Last Update Date: 05/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

572 RIO LINDO AVE STE 104B&D
CHICO CA
95926
US

IV. Provider business mailing address

PO BOX 1476
PARADISE CA
95967-1476
US

V. Phone/Fax

Practice location:
  • Phone: 530-877-4786
  • Fax: 530-894-5791
Mailing address:
  • Phone: 530-877-8187
  • Fax: 530-894-5791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROSEMARY LISA KELLY
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 530-894-5933