Provider Demographics
| NPI: | 1588914824 |
|---|---|
| Name: | ADVANCING YOUTH'S ACADEMY, INC |
| Entity type: | Organization |
| Organization Name: | ADVANCING YOUTH'S ACADEMY, INC |
| Other - Org Name: | <UNAVAIL> |
| Other - Org Type: | |
| Authorized Official - Title/Position: | CEO |
| Authorized Official - Prefix: | DR |
| Authorized Official - First Name: | ROMMYS |
| Authorized Official - Middle Name: | ALEMANIA |
| Authorized Official - Last Name: | BELTRAN |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | PHD |
| Authorized Official - Phone: | 770-650-0000 |
| Mailing Address - Street 1: | 2662 HOLCOMB BRIDGE RD |
| Mailing Address - Street 2: | SUITES 340, 328, 330 |
| Mailing Address - City: | ALPHARETTA |
| Mailing Address - State: | GA |
| Mailing Address - Zip Code: | 30022-6819 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 770-650-0000 |
| Mailing Address - Fax: | 770-650-0002 |
| Practice Address - Street 1: | 2662 HOLCOMB BRIDGE RD |
| Practice Address - Street 2: | SUITES 340, 328, 330 |
| Practice Address - City: | ALPHARETTA |
| Practice Address - State: | GA |
| Practice Address - Zip Code: | 30022-6819 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 770-650-0000 |
| Practice Address - Fax: | 770-650-0002 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2012-09-13 |
| Last Update Date: | 2015-07-22 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| GA | 125325 | 103T00000X, 101YA0400X |
| GA | APC002972 | 101Y00000X, 103TB0200X |
| GA | 247200000X, 235Z00000X, 103TC2200X, 103TF0000X, 103TP2701X, 101YS0200X, 103TR0400X, 101YP1600X, 103TF0200X | |
| 261QR0400X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 103TF0200X | Behavioral Health & Social Service Providers | Psychologist | Forensic | Group - Single Specialty |
| No | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | Group - Single Specialty | |
| No | 101Y00000X | Behavioral Health & Social Service Providers | Counselor | Group - Single Specialty | |
| No | 103TB0200X | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | Group - Single Specialty |
| No | 247200000X | Technologists, Technicians & Other Technical Service Providers | Technician, Other | Group - Single Specialty | |
| No | 235Z00000X | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | Group - Single Specialty | |
| No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | Group - Single Specialty |
| No | 261QR0400X | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation | Group - Single Specialty |
| No | 103TC2200X | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | Group - Single Specialty |
| No | 103TF0000X | Behavioral Health & Social Service Providers | Psychologist | Family | Group - Single Specialty |
| No | 103TP2701X | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy | Group - Single Specialty |
| No | 101YS0200X | Behavioral Health & Social Service Providers | Counselor | School | Group - Single Specialty |
| No | 103TR0400X | Behavioral Health & Social Service Providers | Psychologist | Rehabilitation | Group - Single Specialty |
| No | 101YP1600X | Behavioral Health & Social Service Providers | Counselor | Pastoral | Group - Single Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| GA | 12471665 | Other | CAQH |
