Healthcare Provider Details

I. General information

NPI: 1275764896
Provider Name (Legal Business Name): APOSTOLIC YOUTH & FAMILY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2009
Last Update Date: 07/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4645 BROADWAY
GARY IN
46409-2461
US

IV. Provider business mailing address

4645 BROADWAY
GARY IN
46409-2461
US

V. Phone/Fax

Practice location:
  • Phone: 219-981-4008
  • Fax: 219-981-9273
Mailing address:
  • Phone: 219-981-4008
  • Fax: 219-981-9273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20042301A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34001842A
License Number StateIN

VIII. Authorized Official

Name: MR. CLIFTON SMITH
Title or Position: EXECUTIVE DIRECTOR
Credential: LCSW
Phone: 219-981-4008