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General NPI Number Information
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NPI Number | 1013397892
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Entity Type | Organization
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Legal Business Name | IDEA YOUTH SUCCESS CENTER
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Dates
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Enumeration Date | 06/05/2015
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Last Update Date | 06/05/2015
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Provider Practice Location Address
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Address Line | 1518 VAUGHN BLVD
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City | FORT WORTH
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State | TX
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Zip | 76105-2307
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Country | US
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Telephone | 214-515-2079
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Fax |
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Provider Business Mailing Address
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Address Line | 608 CHAPEL PL
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City | CEDAR HILL
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State | TX
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Zip | 75104-1760
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. DETITRIA WOODARD
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Credential |
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Telephone | 214-515-2079
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3245S0500X
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Taxonomy Name | Children's Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number |
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License Number State |
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