Basic Information
| Provider Information | |||||||||
| NPI: | 1619117397 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | YOUTHVILLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4505 E 47TH ST S | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672101651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3165299100 | ||||||||
| FaxNumber: | 3165299351 | ||||||||
| Practice Location | |||||||||
| Address1: | 4505 E 47TH ST S | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672101651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3165299100 | ||||||||
| FaxNumber: | 3165299351 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2009 | ||||||||
| LastUpdateDate: | 02/20/2009 | ||||||||
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| AuthorizedOfficialLastName: | GLENDENING | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | RENE | ||||||||
| AuthorizedOfficialTitleorPosition: | TRAUMA SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 3165299100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LPC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 253J00000X | LCP 2053 | KS | Y | Agencies | Foster Care Agency |
No ID Information.