Healthcare Provider Details

I. General information

NPI: 1750508040
Provider Name (Legal Business Name): YOUTH ACADEMY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 CROSSWINDS DR
FAIRMONT WV
26554-9193
US

IV. Provider business mailing address

3 CROSSWINDS DR
FAIRMONT WV
26554-9193
US

V. Phone/Fax

Practice location:
  • Phone: 304-363-3341
  • Fax: 304-363-3342
Mailing address:
  • Phone: 304-363-3341
  • Fax: 304-363-3342

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: STEVEN W. FAIRLEY
Title or Position: EXECUTIVE DIRECTOR
Credential: LCSW, ACSW, MSW
Phone: 304-363-3341