=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780822429
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAIRBANKS YOUTH ADVOCATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2009
-----------------------------------------------------
Last Update Date | 12/29/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 122 10TH AVENUE
-----------------------------------------------------
City | FAIRBANKS
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-457-6002
-----------------------------------------------------
Fax | 907-457-3610
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 10337
-----------------------------------------------------
City | FAIRBANKS
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99710-0337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-457-6002
-----------------------------------------------------
Fax | 907-457-3610
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL DIRECTOR
-----------------------------------------------------
Name | MR. DAVID B. BATES
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 907-457-6002
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 408
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------