Basic Information
Provider Information | |||||||||
NPI: | 1720436488 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | YOUTH OPPORTUNITY CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3700 W KILGORE AVE | ||||||||
Address2: |   | ||||||||
City: | MUNCIE | ||||||||
State: | IN | ||||||||
PostalCode: | 473044810 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7652895437 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 103 W COUNTY ROAD 100 N | ||||||||
Address2: |   | ||||||||
City: | NEW CASTLE | ||||||||
State: | IN | ||||||||
PostalCode: | 473628965 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7652895437 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/02/2016 | ||||||||
LastUpdateDate: | 06/02/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ANDERSON | ||||||||
AuthorizedOfficialFirstName: | PAULA | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF COMPLIANCE | ||||||||
AuthorizedOfficialTelephone: | 7652895437 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.A., OHCC | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TH0100X | 20042827 | IN | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Health Service | 103TH0100X | 20042841 | IN | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Health Service | 2084P0800X | 01038611 | IN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 103TH0100X | 20042451 | IN | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Health Service |
No ID Information.