Healthcare Provider Details

I. General information

NPI: 1134327679
Provider Name (Legal Business Name): YOUTH DEVELOPMENT SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

271 STANDISH AVE
HACKENSACK NJ
07601-1716
US

IV. Provider business mailing address

6658 SINKHOLE RD
AMBROSE GA
31512-3890
US

V. Phone/Fax

Practice location:
  • Phone: 201-543-3935
  • Fax:
Mailing address:
  • Phone: 912-389-1205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0036587
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name: TARA J SPATES
Title or Position: AUTHORIZED MEMBER
Credential:
Phone: 912-389-1205