Provider Demographics
NPI:1902169253
Name:THE SALVATION ARMY
Entity Type:Organization
Organization Name:THE SALVATION ARMY
Other - Org Name:BOOTH MEMORIAL YOUTH & FAMILY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:EGGLESTON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:907-375-3505
Mailing Address - Street 1:143 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99501-3618
Mailing Address - Country:US
Mailing Address - Phone:907-375-3505
Mailing Address - Fax:907-279-0522
Practice Address - Street 1:3600 E 20TH AVE
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508
Practice Address - Country:US
Practice Address - Phone:907-375-3505
Practice Address - Fax:907-279-0522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-21
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X, 322D00000X, 324500000X, 3245S0500X
AK3245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children