Healthcare Provider Details

I. General information

NPI: 1689327330
Provider Name (Legal Business Name): NATIONAL YOUTH ADVOCATE PROGRAM, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2022
Last Update Date: 02/02/2022
Certification Date: 02/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 217TH PL
SAUK VILLAGE IL
60411-4462
US

IV. Provider business mailing address

1801 WATERMARK DR STE 200
COLUMBUS OH
43215-7088
US

V. Phone/Fax

Practice location:
  • Phone: 708-747-2655
  • Fax: 708-747-2859
Mailing address:
  • Phone: 614-487-8758
  • 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 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