Healthcare Provider Details

I. General information

NPI: 1568678514
Provider Name (Legal Business Name): SANTA ROSA YOUTH ACADEMY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 07/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12364 ENVIRONMENTAL CENTER RD
HOLT FL
32564-9126
US

IV. Provider business mailing address

12364 ENVIRONMENTAL CENTER RD
HOLT FL
32564-9126
US

V. Phone/Fax

Practice location:
  • Phone: 850-957-3600
  • Fax: 850-957-9000
Mailing address:
  • Phone: 850-957-3600
  • Fax: 850-957-9000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number0157AD569002
License Number StateFL

VIII. Authorized Official

Name: MS. MICHELLE MOODY
Title or Position: CLINICAL DIRECTOR
Credential: L.C.S.W.
Phone: 850-957-3600