Healthcare Provider Details

I. General information

NPI: 1982359139
Provider Name (Legal Business Name): NATIONAL YOUTH ADVOCATE PROGRAM, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2022
Last Update Date: 06/21/2022
Certification Date: 06/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1621 N MISSOURI AVE
PEORIA IL
61603-3124
US

IV. Provider business mailing address

4801 SOUTHWICK DR STE 300
MATTESON IL
60443-2279
US

V. Phone/Fax

Practice location:
  • Phone: 708-747-2655
  • Fax: 708-747-2859
Mailing address:
  • Phone: 708-747-2655
  • Fax: 708-747-2859

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 Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: SHELIA OWENS
Title or Position: DIRECTOR OF DEVELOPMENT
Credential:
Phone: 708-747-2655