Healthcare Provider Details

I. General information

NPI: 1609233410
Provider Name (Legal Business Name): ADULT YOUTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2016
Last Update Date: 01/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 N WAHSATCH AVE STE 101
COLORADO SPRINGS CO
80903-3479
US

IV. Provider business mailing address

223 N WAHSATCH AVE STE 101
COLORADO SPRINGS CO
80903-3479
US

V. Phone/Fax

Practice location:
  • Phone: 719-442-1779
  • Fax: 719-442-0538
Mailing address:
  • Phone: 719-442-1779
  • Fax: 719-442-0538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MARY GUPTON-JOHNSON
Title or Position: OWNER/CEO
Credential: MSW
Phone: 719-442-1779