Provider Demographics
NPI:1003994245
Name:SOUTHSIDE YOUTH COUNCIL, INC
Entity Type:Organization
Organization Name:SOUTHSIDE YOUTH COUNCIL, INC
Other - Org Name:REACH FOR YOUTH, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT, EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:NUNN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-920-5900
Mailing Address - Street 1:3505 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46205-3718
Mailing Address - Country:US
Mailing Address - Phone:317-920-5900
Mailing Address - Fax:317-920-5911
Practice Address - Street 1:5401 SHELBY ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-4216
Practice Address - Country:US
Practice Address - Phone:317-788-4451
Practice Address - Fax:317-788-4465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100071720Medicaid