Healthcare Provider Details

I. General information

NPI: 1699685313
Provider Name (Legal Business Name): COMMUNITY YOUTH IMPACT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7733 LINDA LAKE DR
CHARLOTTE NC
28215-2846
US

IV. Provider business mailing address

7733 LINDA LAKE DR
CHARLOTTE NC
28215-2846
US

V. Phone/Fax

Practice location:
  • Phone: 919-395-6766
  • Fax:
Mailing address:
  • Phone: 919-395-6766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: STEVIIN CYEL JAMES
Title or Position: MANAGING PARTNER
Credential:
Phone: 919-395-6766