Healthcare Provider Details

I. General information

NPI: 1457562902
Provider Name (Legal Business Name): YOUTHVILLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11200 LARIAT WAY
DODGE CITY KS
67801-7328
US

IV. Provider business mailing address

900 W BROADWAY ST
NEWTON KS
67114-2037
US

V. Phone/Fax

Practice location:
  • Phone: 620-225-0276
  • Fax: 620-225-1854
Mailing address:
  • Phone: 316-283-1950
  • Fax: 316-283-9540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number850
License Number StateKS

VIII. Authorized Official

Name: MR. FRANK B SUMAYA
Title or Position: THERAPIST-COUNSELOR
Credential: MASTERS DEGREE
Phone: 620-225-0276