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General NPI Number Information
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NPI Number | 1518219922
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Entity Type | Organization
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Legal Business Name | INSTITUTE FOR THE DEVELOPEMENT OF AFRICAN AMERICAN YOUTH
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Dates
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Enumeration Date | 10/09/2012
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Last Update Date | 10/09/2012
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Provider Practice Location Address
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Address Line | 1701 W CHELTEN AVE STE 101A
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City | PHILADELPHIA
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State | PA
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Zip | 19126-3410
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Country | US
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Telephone | 215-276-5354
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Fax | 215-276-5357
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Provider Business Mailing Address
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Address Line | PO BOX 2061
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City | PHILADELPHIA
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State | PA
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Zip | 19103-0061
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Country | US
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Telephone | 215-235-9116
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Fax | 215-235-9128
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. ARCHYE LEACOCK
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Credential |
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Telephone | 215-235-9116
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State |
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