MEDICARE: ALTERNATIVE YOUTH SERVICES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1497378111
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALTERNATIVE YOUTH SERVICES, INC.

Provider Business Mailing Address
First Line	:	805 N WHITTINGTON PKWY
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40222-7101
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11218 PROFESSIONAL PARK DR
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40291-4476
Country	:	US
Telephone Number	:	502-239-4959
Fax Number	:

Authorized Official
Title or Position	:	MANAGER-PROVIDER ENROLLMENT
Name	:	ANGIE MATTINGLY
Credential	:
Telephone Number	:	502-381-3579

Provider Enumeration Date	:	05/28/2020
Last Update Date	:	05/28/2020

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