Healthcare Provider Details

I. General information

NPI: 1538319421
Provider Name (Legal Business Name): YOUTH OPPORTUNITY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2008
Last Update Date: 09/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 W KILGORE AVE
MUNCIE IN
47304-4810
US

IV. Provider business mailing address

3700 W KILGORE AVE
MUNCIE IN
47304-4810
US

V. Phone/Fax

Practice location:
  • Phone: 765-289-5437
  • Fax: 765-213-5094
Mailing address:
  • Phone: 765-289-5437
  • Fax: 765-213-5094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number20042115A
License Number StateIN

VIII. Authorized Official

Name: MR. RICHARD D. ROWRAY
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 765-289-5437