Healthcare Provider Details

I. General information

NPI: 1629099890
Provider Name (Legal Business Name): MARION YOUTH DEVELOPMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4055 NW 105TH ST
OCALA FL
34482-1434
US

IV. Provider business mailing address

4055 NW 105TH ST
OCALA FL
34482-1434
US

V. Phone/Fax

Practice location:
  • Phone: 352-671-2777
  • Fax: 352-368-5940
Mailing address:
  • Phone: 352-671-2777
  • Fax: 352-368-5940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number1342AD5690
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. BRENDA LYNN CARLSON
Title or Position: CLINICAL DIRECTOR
Credential: L.M.H.C.
Phone: 352-671-2777