Provider Demographics
NPI:1528741337
Name:TEACHING OUR YOUTH EXCELLENCE
Entity type:Organization
Organization Name:TEACHING OUR YOUTH EXCELLENCE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED COMMUNITY HEALTH WORKER
Authorized Official - Prefix:
Authorized Official - First Name:LAKISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:DSHS CHW
Authorized Official - Phone:682-438-3346
Mailing Address - Street 1:4516 WILLOW ROCK LN
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-4332
Mailing Address - Country:US
Mailing Address - Phone:682-438-3346
Mailing Address - Fax:
Practice Address - Street 1:2451 W GRAPEVINE MILLS CIR
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-2096
Practice Address - Country:US
Practice Address - Phone:682-438-3346
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-09
Last Update Date:2024-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes372600000XNursing Service Related ProvidersAdult CompanionGroup - Single Specialty
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No385HR2050XRespite Care FacilityRespite CareRespite Care CampGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1528741337Medicaid
TX1427741354Medicaid
TX1922785765Medicaid