Healthcare Provider Details

I. General information

NPI: 1508936238
Provider Name (Legal Business Name): ELEVATE YOUTH SERVICES INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 11/26/2024
Certification Date: 11/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

652 GRANGER RD
BARRE VT
05641-5363
US

IV. Provider business mailing address

652 GRANGER RD
BARRE VT
05641-5363
US

V. Phone/Fax

Practice location:
  • Phone: 802-229-9151
  • Fax: 802-229-2508
Mailing address:
  • Phone: 802-229-9151
  • Fax: 802-229-2508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number000350
License Number StateVT
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number0470000720
License Number StateVT
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0890000651
License Number StateVT

VIII. Authorized Official

Name: MS. FAVOR ELLIS
Title or Position: EXECUTIVE DIRECTOR
Credential: MA
Phone: 802-229-9151