Healthcare Provider Details

I. General information

NPI: 1184787269
Provider Name (Legal Business Name): YOUTH PROFILE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 06/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3520 DRAWBRIDGE PKWY APT. D
GREENSBORO NC
27410-9621
US

IV. Provider business mailing address

5683 GREENDALE CT
SUMMERFIELD NC
27358-9156
US

V. Phone/Fax

Practice location:
  • Phone: 336-707-0377
  • Fax: 336-644-1423
Mailing address:
  • Phone: 336-707-0377
  • Fax: 336-644-1423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License NumberMHL-041-637
License Number StateNC

VIII. Authorized Official

Name: MR. ALFRED LEE MCBRIDE
Title or Position: ASSO. EXECUTIVE DIRECTOR
Credential: M.ED.
Phone: 336-707-0377