Provider Demographics
NPI:1336266733
Name:ALEXANDER YOUTH NETWORK
Entity type:Organization
Organization Name:ALEXANDER YOUTH NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:BASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-362-8460
Mailing Address - Street 1:PO BOX 220632
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28222-0632
Mailing Address - Country:US
Mailing Address - Phone:704-366-8712
Mailing Address - Fax:704-362-8464
Practice Address - Street 1:1904 DALLAS CHERRYVILLE HWY
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:NC
Practice Address - Zip Code:28034-7706
Practice Address - Country:US
Practice Address - Phone:704-922-9115
Practice Address - Fax:704-922-0441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301801Medicaid
NC8301458Medicaid
NC8301458RMedicaid
NC8301801RMedicaid