Provider Demographics
NPI:1992546386
Name:PRIDELINES YOUTH SERVICES, INC.
Entity type:Organization
Organization Name:PRIDELINES YOUTH SERVICES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:SUMMERS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:347-468-6621
Mailing Address - Street 1:PO BOX 14340
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33101-4340
Mailing Address - Country:US
Mailing Address - Phone:305-571-9601
Mailing Address - Fax:
Practice Address - Street 1:5525 NW 7TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33127-1401
Practice Address - Country:US
Practice Address - Phone:305-571-9601
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-01
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No251B00000XAgenciesCase Management
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)