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General NPI Number Information
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NPI Number | 1023171758
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Entity Type | Organization
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Legal Business Name | YOUTH PROFILE INC.
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Dates
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Enumeration Date | 12/16/2006
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Last Update Date | 06/13/2008
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Provider Practice Location Address
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Address Line | 4010 COLTRAIN RD
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City | GREENSBORO
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State | NC
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Zip | 27455-2632
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Country | US
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Telephone | 336-545-1612
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Fax | 336-644-1423
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Provider Business Mailing Address
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Address Line | 5683 GREENDALE CT
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City | SUMMERFIELD
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State | NC
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Zip | 27358-9156
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Country | US
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Telephone | 336-707-0377
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Fax | 336-644-1423
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Authorized Official
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Title or Position | ASSO. EXECUTIVE DIRECTOR
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Name | MR. ALFRED LEE MCBRIDE
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Credential | M.ED
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Telephone | 336-707-0377
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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 | MHL-041-204
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License Number State | NC
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