Healthcare Provider Details

I. General information

NPI: 1417262924
Provider Name (Legal Business Name): NATIONAL YOUTH ADVOCATE PROGRAM, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2010
Last Update Date: 01/26/2024
Certification Date: 01/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 SOUTHWICK DR FL 3
MATTESON IL
60443-2254
US

IV. Provider business mailing address

1801 WATERMARK DR SUITE 200
COLUMBUS OH
43215-7088
US

V. Phone/Fax

Practice location:
  • Phone: 866-596-6955
  • Fax: 708-747-2859
Mailing address:
  • Phone: 888-202-2965
  • Fax: 614-487-8759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MARVENA TWIGG
Title or Position: PRESIDENT/CEO
Credential:
Phone: 888-202-2965