Provider Demographics
NPI:1043855851
Name:YOUTH SERVICES NETWORK
Entity Type:Organization
Organization Name:YOUTH SERVICES NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE/LICENSING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCALO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-986-1947
Mailing Address - Street 1:107 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-4010
Mailing Address - Country:US
Mailing Address - Phone:815-986-1947
Mailing Address - Fax:815-986-1954
Practice Address - Street 1:107 N 3RD ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-4010
Practice Address - Country:US
Practice Address - Phone:815-986-1947
Practice Address - Fax:815-986-1954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-15
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3000005Medicaid