Provider Demographics
NPI:1609188853
Name:FAMILY AND YOUTH INTERVENTION SERVICES
Entity Type:Organization
Organization Name:FAMILY AND YOUTH INTERVENTION SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:BAINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-852-4695
Mailing Address - Street 1:PO BOX 842
Mailing Address - Street 2:
Mailing Address - City:OOLOGAH
Mailing Address - State:OK
Mailing Address - Zip Code:74053-0842
Mailing Address - Country:US
Mailing Address - Phone:188-524-6959
Mailing Address - Fax:
Practice Address - Street 1:5037 S 24TH ST STE 2
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85040-2604
Practice Address - Country:US
Practice Address - Phone:602-282-8836
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-04
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health