Healthcare Provider Details

I. General information

NPI: 1295124014
Provider Name (Legal Business Name): NATIONAL YOUTH ADVOCATE PROGRAM, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2015
Last Update Date: 03/21/2022
Certification Date: 03/21/2022
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: 888-688-9964
  • Fax: 614-487-3819

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 StateNULL
# 2
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MARVENA TWIGG
Title or Position: PRESIDENT/CEO
Credential:
Phone: 888-688-9964