Provider Demographics
NPI:1649406877
Name:NATIONAL YOUTH ADVOCATE PROGRAM
Entity Type:Organization
Organization Name:NATIONAL YOUTH ADVOCATE PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARVENA
Authorized Official - Middle Name:
Authorized Official - Last Name:TWIGG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-487-8758
Mailing Address - Street 1:315 W PONCE DE LEON AVE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-2400
Mailing Address - Country:US
Mailing Address - Phone:877-490-6644
Mailing Address - Fax:404-378-3423
Practice Address - Street 1:315 W PONCE DE LEON AVE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-2400
Practice Address - Country:US
Practice Address - Phone:877-490-6644
Practice Address - Fax:404-378-3423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-02
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003179943AMedicaid