Healthcare Provider Details

I. General information

NPI: 1174190714
Provider Name (Legal Business Name): GUILFORD COUNTY YOUTH ACADEMY, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2021
Last Update Date: 10/18/2021
Certification Date: 10/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 E MARKET ST STE C
GREENSBORO NC
27401-6444
US

IV. Provider business mailing address

8 HILLRISE CT
GREENSBORO NC
27405-9771
US

V. Phone/Fax

Practice location:
  • Phone: 336-554-1625
  • Fax:
Mailing address:
  • Phone: 336-554-1625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: CANDICE STATON SCALES
Title or Position: OFFICE MANAGER
Credential:
Phone: 336-554-1625