=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447060439
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NATIONAL YOUTH ADVOCATE PROGRAM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2025
-----------------------------------------------------
Last Update Date | 01/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 701 MARKET ST UNIT 103B
-----------------------------------------------------
City | ST AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32095-8803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-443-9240
-----------------------------------------------------
Fax | 904-297-2292
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1801 WATERMARK DR STE 200
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43215-7088
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-487-8758
-----------------------------------------------------
Fax | 614-487-8759
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | MARVENA TWIGG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 888-202-2965
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------