MEDICARE: IT TAKES A VILLAGE YOUTH AND FAMILY SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency
2	261QM0855X	Adolescent and Children Mental Health Clinic/Center		NC

General Provider Information

NPI Number	:	1013156942
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IT TAKES A VILLAGE YOUTH AND FAMILY SERVICES

Provider Business Mailing Address
First Line	:	5736 N TRYON ST
Second Line	:	SUITE 105, 116
City	:	CHARLOTTE
State	:	NC
Zip	:	28213-6850
Country	:	US
Telephone Number	:	980-819-7448
Fax Number	:	980-819-7449

Provider Business Practice Location Address
First Line	:	5736 N TRYON ST
Second Line	:	SUITE 105,116
City	:	CHARLOTTE
State	:	NC
Zip	:	28213-6850
Country	:	US
Telephone Number	:	980-819-7448
Fax Number	:	980-819-7449

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. DENNIS DIXON
Credential	:	OWNER
Telephone Number	:	980-819-7448

Provider Enumeration Date	:	02/17/2009
Last Update Date	:	06/14/2012

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