Healthcare Provider Details

I. General information

NPI: 1275386021
Provider Name (Legal Business Name): SUMMIT YOUTH ACADEMY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2024
Last Update Date: 04/10/2024
Certification Date: 04/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 W MAIN ST
EMMETT ID
83617-3470
US

IV. Provider business mailing address

330 W MAIN ST
EMMETT ID
83617-3470
US

V. Phone/Fax

Practice location:
  • Phone: 208-365-3642
  • Fax: 208-365-3687
Mailing address:
  • Phone: 208-365-3642
  • Fax: 208-365-3687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. PAUL CLARK FEAR
Title or Position: OWNER/ADMINISTRATOR
Credential:
Phone: 208-365-3642