Basic Information
| Provider Information | |||||||||
| NPI: | 1073091856 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NATIONAL YOUTH ADVOCATE PROGRAM, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1801 WATERMARK DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432157088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882022965 | ||||||||
| FaxNumber: | 6142279447 | ||||||||
| Practice Location | |||||||||
| Address1: | 1902 W CERMAK RD | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606084204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8554606119 | ||||||||
| FaxNumber: | 7733608379 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2018 | ||||||||
| LastUpdateDate: | 03/03/2020 | ||||||||
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| AuthorizedOfficialLastName: | LIZARDI | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
| AuthorizedOfficialMiddleName: | YVONNE | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAID BILLING SPECIALIST II | ||||||||
| AuthorizedOfficialTelephone: | 6142279430 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPC | ||||||||
| NPICertificationDate: | 03/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.