Healthcare Provider Details

I. General information

NPI: 1053247866
Provider Name (Legal Business Name): YOUTH101
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2026
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 CEDAR ST APT 416
SAINT PAUL MN
55101-1049
US

IV. Provider business mailing address

345 CEDAR ST APT 416
SAINT PAUL MN
55101-1049
US

V. Phone/Fax

Practice location:
  • Phone: 773-454-9573
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: ANDREA POWELL
Title or Position: OFFICER
Credential:
Phone: 773-454-9573