Provider Demographics
NPI:1477991941
Name:SOUTH CAROLINA YOUTH ADVOCATE PROGRAM
Entity Type:Organization
Organization Name:SOUTH CAROLINA YOUTH ADVOCATE PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LEX
Authorized Official - Middle Name:
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-779-5500
Mailing Address - Street 1:140 STONERIDGE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-8200
Mailing Address - Country:US
Mailing Address - Phone:803-779-5500
Mailing Address - Fax:803-779-8444
Practice Address - Street 1:140 STONERIDGE DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210-8200
Practice Address - Country:US
Practice Address - Phone:803-779-5500
Practice Address - Fax:803-779-8444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-06
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC998MXHMedicaid
SCGP6237Medicaid