Provider Demographics
NPI:1447533013
Name:PANAMA YOUTH SERVICES, INC
Entity type:Organization
Organization Name:PANAMA YOUTH SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MS
Authorized Official - Phone:904-527-3953
Mailing Address - Street 1:402 EAST 63RD STREET
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32208
Mailing Address - Country:US
Mailing Address - Phone:904-527-3953
Mailing Address - Fax:904-683-0067
Practice Address - Street 1:7287 WILDER AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32208
Practice Address - Country:US
Practice Address - Phone:904-527-3953
Practice Address - Fax:904-683-0067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0416AD444101101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty