Provider Demographics
NPI:1780987057
Name:YOUTH AGAINST SUBSTANCE ABUSE, INC
Entity type:Organization
Organization Name:YOUTH AGAINST SUBSTANCE ABUSE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/TARGET CASE MANGHAM
Authorized Official - Prefix:MS
Authorized Official - First Name:VONZELIA
Authorized Official - Middle Name:PICKETT
Authorized Official - Last Name:MANGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:BSW/TCM
Authorized Official - Phone:407-970-8019
Mailing Address - Street 1:5004 BRIAR OAKS CIRCLE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32808-1708
Mailing Address - Country:US
Mailing Address - Phone:407-970-8019
Mailing Address - Fax:407-578-3094
Practice Address - Street 1:5004 BRIAR OAKS CIRCLE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32808-1708
Practice Address - Country:US
Practice Address - Phone:407-970-8019
Practice Address - Fax:407-578-3094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-08
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001674900Medicaid