Provider Demographics
NPI:1619193299
Name:THE YOUTH SUCCESS NETWORK LLC
Entity Type:Organization
Organization Name:THE YOUTH SUCCESS NETWORK LLC
Other - Org Name:TYSN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:SETSUO
Authorized Official - Last Name:ISHIBASHI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:551-574-8739
Mailing Address - Street 1:375 SYLVAN AVE
Mailing Address - Street 2:SUITE 30
Mailing Address - City:ENGLEWOOD CLIFFS
Mailing Address - State:NJ
Mailing Address - Zip Code:07632-2725
Mailing Address - Country:US
Mailing Address - Phone:201-731-3739
Mailing Address - Fax:201-732-3582
Practice Address - Street 1:375 SYLVAN AVE
Practice Address - Street 2:SUITE 30
Practice Address - City:ENGLEWOOD CLIFFS
Practice Address - State:NJ
Practice Address - Zip Code:07632-2725
Practice Address - Country:US
Practice Address - Phone:201-731-3739
Practice Address - Fax:201-731-3582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ64669006251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0030872Medicaid