Healthcare Provider Details

I. General information

NPI: 1528741337
Provider Name (Legal Business Name): TEACHING OUR YOUTH EXCELLENCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2023
Last Update Date: 02/04/2024
Certification Date: 02/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2451 W GRAPEVINE MILLS CIR
GRAPEVINE TX
76051-2096
US

IV. Provider business mailing address

4516 WILLOW ROCK LN
FORT WORTH TX
76244-4332
US

V. Phone/Fax

Practice location:
  • Phone: 682-438-3346
  • Fax:
Mailing address:
  • Phone: 682-438-3346
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385HR2050X
TaxonomyRespite Care Camp
License Number
License Number State

VIII. Authorized Official

Name: LAKISHA GIBSON
Title or Position: CERTIFIED COMMUNITY HEALTH WORKER
Credential: DSHS CHW
Phone: 682-438-3346