Healthcare Provider Details

I. General information

NPI: 1831323195
Provider Name (Legal Business Name): STAR ACADEMY FOR YOUTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2009
Last Update Date: 05/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12279 BRADY DR
CUSTER SD
57730-9160
US

IV. Provider business mailing address

12279 BRADY DR
CUSTER SD
57730-9160
US

V. Phone/Fax

Practice location:
  • Phone: 605-673-2521
  • Fax: 605-673-4654
Mailing address:
  • Phone: 605-673-2521
  • Fax: 605-673-4654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number5000360
License Number StateSD

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MR. JEFF BATHKE
Title or Position: PROGRAM ADMINISTRATOR
Credential:
Phone: 605-773-3123