=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457748899
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | YOUTH HAVEN SERVICES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2015
-----------------------------------------------------
Last Update Date | 10/21/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 131 PLANT ST
-----------------------------------------------------
City | WALNUT COVE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27052-9223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-983-5824
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 229 TURNER DR
-----------------------------------------------------
City | REIDSVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27320-5736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-349-2233
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DAWN JOHNSON
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 336-349-2233
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------