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General NPI Number Information
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NPI Number | 1871662882
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Entity Type | Organization
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Legal Business Name | ILLINOIS YOUTH ADVOCATE PROGRAM
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Dates
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Enumeration Date | 11/06/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 191 W 155TH PL
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City | HARVEY
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State | IL
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Zip | 60426-3413
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Country | US
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Telephone | 708-596-6955
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Fax | 708-596-7464
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Provider Business Mailing Address
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Address Line | 191 W 155TH PL
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City | HARVEY
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State | IL
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Zip | 60426-3413
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Country | US
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Telephone | 708-596-6955
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Fax | 708-596-7464
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. EDWARD M. FARMER
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Credential | M.A.
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Telephone | 708-596-6955
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 338374-06
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License Number State | IL
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