Healthcare Provider Details

I. General information

NPI: 1144542127
Provider Name (Legal Business Name): YOUTH SERVICE BUREAU
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2010
Last Update Date: 02/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

734 W DELAWARE ST SUITE 206
EVANSVILLE IN
47710-1667
US

IV. Provider business mailing address

734 W DELAWARE ST SUITE 206
EVANSVILLE IN
47710-1667
US

V. Phone/Fax

Practice location:
  • Phone: 812-423-5816
  • Fax: 812-423-5294
Mailing address:
  • Phone: 812-423-5816
  • Fax: 812-423-5294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39002097A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number39002097A
License Number StateIN

VIII. Authorized Official

Name: MR. TIMOTHY B. THARP
Title or Position: DIRECTOR
Credential: M.S., LCPC
Phone: 812-423-5816