Basic Information
| Provider Information | |||||||||
| NPI: | 1487112751 | ||||||||
| 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: | 6144878759 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 LAKE AVE STE 225 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468055364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2607020360 | ||||||||
| FaxNumber: | 2608182300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2019 | ||||||||
| LastUpdateDate: | 05/07/2020 | ||||||||
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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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| NPICertificationDate: | 05/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.