Provider Demographics
NPI:1326002122
Name:OHIO YOUTH ADVOCATE PROGRAM
Entity Type:Organization
Organization Name:OHIO YOUTH ADVOCATE PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-921-2111
Mailing Address - Street 1:6233 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-5069
Mailing Address - Country:US
Mailing Address - Phone:614-717-8000
Mailing Address - Fax:614-717-8020
Practice Address - Street 1:1445 SUMMIT ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43201-2105
Practice Address - Country:US
Practice Address - Phone:614-523-1001
Practice Address - Fax:614-583-1003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH353251K00000X
OH10709251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH10178Medicaid