Healthcare Provider Details

I. General information

NPI: 1073091856
Provider Name (Legal Business Name): NATIONAL YOUTH ADVOCATE PROGRAM, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2018
Last Update Date: 11/30/2022
Certification Date: 02/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1902 W CERMAK RD
CHICAGO IL
60608-4204
US

IV. Provider business mailing address

1801 WATERMARK DR STE 200
COLUMBUS OH
43215-7088
US

V. Phone/Fax

Practice location:
  • Phone: 855-460-6119
  • Fax: 773-360-8379
Mailing address:
  • Phone: 888-202-2965
  • Fax: 614-227-9447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE YVONNE LIZARDI
Title or Position: MEDICAID BILLING SPECIALIST II
Credential: CPC
Phone: 614-227-9430