Healthcare Provider Details

I. General information

NPI: 1053178574
Provider Name (Legal Business Name): YOUTH EMPORIUM INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2024
Last Update Date: 03/01/2024
Certification Date: 03/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 CHAPEL HILL RD
DOUGLASVILLE GA
30135-1739
US

IV. Provider business mailing address

3400 CHAPEL HILL RD
DOUGLASVILLE GA
30135-1739
US

V. Phone/Fax

Practice location:
  • Phone: 678-521-5245
  • Fax: 678-812-3633
Mailing address:
  • Phone: 678-521-5245
  • Fax: 678-812-3633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number StateNULL
# 7
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. BRENDA L HILLMAN
Title or Position: PRESIDENT & EX. DIRECTOR
Credential: DR, MSPSL, BA
Phone: 678-521-5245