Healthcare Provider Details

I. General information

NPI: 1720436488
Provider Name (Legal Business Name): YOUTH OPPORTUNITY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2016
Last Update Date: 06/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 W COUNTY ROAD 100 N
NEW CASTLE IN
47362-8965
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:
Mailing address:
  • Phone: 765-289-5437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number20042827
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number20042841
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number01038611
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number20042451
License Number StateIN

VIII. Authorized Official

Name: MRS. PAULA D ANDERSON
Title or Position: DIRECTOR OF COMPLIANCE
Credential: M.A., OHCC
Phone: 765-289-5437