Provider Demographics
NPI:1902996721
Name:YOUTH TOWN OF TENNESSEE, INC.
Entity Type:Organization
Organization Name:YOUTH TOWN OF TENNESSEE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:NICK
Authorized Official - Middle Name:
Authorized Official - Last Name:SUMMAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-988-5251
Mailing Address - Street 1:PO BOX 1385
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38302-1385
Mailing Address - Country:US
Mailing Address - Phone:731-988-5251
Mailing Address - Fax:731-427-5605
Practice Address - Street 1:3641 YOUTH TOWN RD
Practice Address - Street 2:
Practice Address - City:PINSON
Practice Address - State:TN
Practice Address - Zip Code:38366-9804
Practice Address - Country:US
Practice Address - Phone:731-988-5251
Practice Address - Fax:731-427-5605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNI000000002836101YA0400X, 101YM0800X
TN0000000507324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5441227Medicaid