Basic Information
| Provider Information | |||||||||
| NPI: | 1508397340 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NATIONAL YOUTH ADVOCATE PROGRAM, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1801 WATERMARK DR | ||||||||
| Address2: | STE 200 | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432157088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8886889964 | ||||||||
| FaxNumber: | 6144873819 | ||||||||
| Practice Location | |||||||||
| Address1: | 7 WAVELAND AVE | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403911231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593854669 | ||||||||
| FaxNumber: | 8592011450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2017 | ||||||||
| LastUpdateDate: | 08/07/2020 | ||||||||
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| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | KIARA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 6148242197 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 253J00000X | N | Agencies | Foster Care Agency | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 7100485520 | 05 | KY | MEDICAID |