Provider Demographics
NPI:1659825560
Name:YOUTH OUTREACH SERVICES
Entity Type:Organization
Organization Name:YOUTH OUTREACH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICK
Authorized Official - Middle Name:
Authorized Official - Last Name:VELASQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:773-777-7112
Mailing Address - Street 1:2411 W CONGRESS PKWY
Mailing Address - Street 2:YOUTH OUTREACH SERVICES
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3534
Mailing Address - Country:US
Mailing Address - Phone:773-777-7112
Mailing Address - Fax:773-777-7611
Practice Address - Street 1:6417 W IRVING PARK RD
Practice Address - Street 2:YOUTH OUTREACH SERVICES
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-2437
Practice Address - Country:US
Practice Address - Phone:773-777-7112
Practice Address - Fax:773-777-7059
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:YOUTH OUTREACH SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-08-09
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA-0534-0005-A251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2B05-IPI-144Medicaid