Healthcare Provider Details

I. General information

NPI: 1366486680
Provider Name (Legal Business Name): TEEN CHALLENGE OF FLORIDA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 01/25/2021
Certification Date: 01/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 W WEBSTER ST
SEBREE KY
42455
US

IV. Provider business mailing address

15 W 10TH ST
COLUMBUS GA
31901-2744
US

V. Phone/Fax

Practice location:
  • Phone: 484-868-0584
  • Fax:
Mailing address:
  • Phone: 706-596-8731
  • Fax: 706-596-8732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number0759AD922801
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. BRICE MADDOCK
Title or Position: CEO
Credential:
Phone: 706-596-8731