Basic Information
| Provider Information | |||||||||
| NPI: | 1235408022 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NATIONAL YOUTH ADVOCATE PROGRAM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1801 WATERMARK DR | ||||||||
| Address2: | STE 200 | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432157088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882022965 | ||||||||
| FaxNumber: | 6144878759 | ||||||||
| Practice Location | |||||||||
| Address1: | 4701 N KEYSTONE AVE STE 150 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462051562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004714795 | ||||||||
| FaxNumber: | 3174750081 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2011 | ||||||||
| LastUpdateDate: | 03/05/2019 | ||||||||
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| AuthorizedOfficialLastName: | TWIGG | ||||||||
| AuthorizedOfficialFirstName: | MARVENA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 8882022965 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | IN | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 201052480 A | 05 | IN | MEDICAID |