MEDICARE: YOUTH INTERACTIVE PREVENTION SERVICES INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	1041C0700X	Clinical Social Worker
2	251S00000X	Community/Behavioral Health Agency
3	252Y00000X	Early Intervention Provider Agency

General Provider Information

NPI Number	:	1669709515
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	YOUTH INTERACTIVE PREVENTION SERVICES INC

Provider Business Mailing Address
First Line	:	152 E MAIN ST
Second Line	:
City	:	JEROME
State	:	ID
Zip	:	83338-2333
Country	:	US
Telephone Number	:	208-324-6885
Fax Number	:

Provider Business Practice Location Address
First Line	:	152 E MAIN ST
Second Line	:
City	:	JEROME
State	:	ID
Zip	:	83338-2333
Country	:	US
Telephone Number	:	208-324-6885
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MRS. PATRISHA MARIE BORRESEN
Credential	:
Telephone Number	:	208-324-6885

Provider Enumeration Date	:	11/13/2009
Last Update Date	:	11/13/2009

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