MEDICARE: LRB YOUTH DEVELOPMENT

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1922565399
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LRB YOUTH DEVELOPMENT

Provider Business Mailing Address
First Line	:	1537 DIAMOND RD
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28311-1895
Country	:	US
Telephone Number	:	910-987-9395
Fax Number	:

Provider Business Practice Location Address
First Line	:	3654 S IRBY ST
Second Line	:
City	:	FLORENCE
State	:	SC
Zip	:	29505-5225
Country	:	US
Telephone Number	:	910-987-9395
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. LINTRESE JANEA ROBINSON
Credential	:
Telephone Number	:	910-987-9395

Provider Enumeration Date	:	02/21/2019
Last Update Date	:	02/21/2019

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Directions to “LRB YOUTH DEVELOPMENT ” Practice Location

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