Provider Demographics
NPI:1568678514
Name:SANTA ROSA YOUTH ACADEMY
Entity type:Organization
Organization Name:SANTA ROSA YOUTH ACADEMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOODY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:850-957-3600
Mailing Address - Street 1:12364 ENVIRONMENTAL CENTER RD
Mailing Address - Street 2:
Mailing Address - City:HOLT
Mailing Address - State:FL
Mailing Address - Zip Code:32564-9126
Mailing Address - Country:US
Mailing Address - Phone:850-957-3600
Mailing Address - Fax:850-957-9000
Practice Address - Street 1:12364 ENVIRONMENTAL CENTER RD
Practice Address - Street 2:
Practice Address - City:HOLT
Practice Address - State:FL
Practice Address - Zip Code:32564-9126
Practice Address - Country:US
Practice Address - Phone:850-957-3600
Practice Address - Fax:850-957-9000
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:YOUTH SERVICES INTERNATIONAL, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-15
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
322D00000X
FL0157AD5690023245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7684541Medicaid
FL070956502Medicaid