Healthcare Provider Details

I. General information

NPI: 1366381626
Provider Name (Legal Business Name): ELEVATION YOUTH LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2026
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1917 PETTY RD
KINGSTOWN NC
28150-8826
US

IV. Provider business mailing address

1917 PETTY RD
KINGSTOWN NC
28150-8826
US

V. Phone/Fax

Practice location:
  • Phone: 980-525-2566
  • Fax:
Mailing address:
  • Phone: 980-525-2566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: DEIDRE HUDSON
Title or Position: OWNER/CEO
Credential:
Phone: 980-525-2566