Healthcare Provider Details

I. General information

NPI: 1265751762
Provider Name (Legal Business Name): ST JOHNS YOUTH ACADEMY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2010
Last Update Date: 05/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 AVENUE D
ST AUGUSTINE FL
32095-5245
US

IV. Provider business mailing address

4500 AVENUE D
ST AUGUSTINE FL
32095-5245
US

V. Phone/Fax

Practice location:
  • Phone: 904-829-8850
  • Fax: 904-829-8851
Mailing address:
  • Phone: 904-829-8850
  • Fax: 904-829-8851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number0755AD5690-09
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. BARIKA GRAYSON
Title or Position: CLINICAL DIRECTOR
Credential: L.M.H.C.
Phone: 904-829-8850