Provider Demographics
NPI:1558603472
Name:OUT YOUTH
Entity Type:Organization
Organization Name:OUT YOUTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:AUBREY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-419-1233
Mailing Address - Street 1:909 E 49TH 1/2 ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78751-2714
Mailing Address - Country:US
Mailing Address - Phone:512-419-1233
Mailing Address - Fax:
Practice Address - Street 1:909 E 49TH 1/2 ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78751-2714
Practice Address - Country:US
Practice Address - Phone:512-419-1233
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-18
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health