Provider Demographics
NPI:1043447733
Name:SUPREME YOUTH DEVELOPMENT CENTER
Entity type:Organization
Organization Name:SUPREME YOUTH DEVELOPMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/FOUNDER
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:BROADY
Authorized Official - Suffix:
Authorized Official - Credentials:BSW
Authorized Official - Phone:919-824-0891
Mailing Address - Street 1:4704 COURTNEY LN APT C
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-5251
Mailing Address - Country:US
Mailing Address - Phone:919-824-0891
Mailing Address - Fax:919-803-2356
Practice Address - Street 1:4704 COURTNEY LN APT C
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27616-5251
Practice Address - Country:US
Practice Address - Phone:919-824-0891
Practice Address - Fax:919-803-2356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-19
Last Update Date:2009-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health