Healthcare Provider Details

I. General information

NPI: 1013089002
Provider Name (Legal Business Name): YOUTH DEVELOPMENT INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1820 SAN PEDRO DR NE SUITE 7 & 8
ALBUQUERQUE NM
87110-5937
US

IV. Provider business mailing address

1710 EL CENTRO FAMILIAR BLVD SW
ALBUQUERQUE NM
87105-4502
US

V. Phone/Fax

Practice location:
  • Phone: 505-232-9015
  • Fax: 505-232-9017
Mailing address:
  • Phone: 505-873-1604
  • Fax: 505-877-3533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: LYNDA MOORE
Title or Position: CLINICAL DIRECTOR
Credential: LPCC
Phone: 505-873-1604