1023490794 NPI number — CENTRAL LYON YOUTH CONNECTIONS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023490794 NPI number — CENTRAL LYON YOUTH CONNECTIONS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRAL LYON YOUTH CONNECTIONS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023490794
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/18/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 1865
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAYTON
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89403
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
775-246-0320
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
170 PIKE STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAYTON
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-246-0320
Provider Business Practice Location Address Fax Number:
775-246-7553
Provider Enumeration Date:
06/18/2015

Additional Information

Authorized Official

Authorized Official Last Name:
WATKINS
Authorized Official First Name:
MICHELE
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
EXECUTIVE DIRECTOR, LCSW
Authorized Official Telephone Number:
775-246-0320

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  6731-C , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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