Healthcare Provider Details

I. General information

NPI: 1336218486
Provider Name (Legal Business Name): ECKERD YOUTH ALTERNATIVES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 11/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4654 HIGH ROCK RD
BOOMER NC
28606-9109
US

IV. Provider business mailing address

100 STARCREST DR
CLEARWATER FL
33765-3224
US

V. Phone/Fax

Practice location:
  • Phone: 336-921-3300
  • Fax: 336-921-4320
Mailing address:
  • Phone: 727-461-2990
  • Fax: 727-216-0055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: NICOLE STROEBEL
Title or Position: CONTROLLER
Credential:
Phone: 727-461-2990