Provider Demographics
NPI:1689081309
Name:THE YOUTH SUCCESS NETWORK LLC
Entity Type:Organization
Organization Name:THE YOUTH SUCCESS NETWORK LLC
Other - Org Name:
Other - Org Type:
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 1:1150 NEWTON ST
Mailing Address - Street 2:SUITE B.
Mailing Address - City:NORTH BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08902-2286
Mailing Address - Country:US
Mailing Address - Phone:888-897-6465
Mailing Address - Fax:877-438-8976
Practice Address - Street 1:1150 NEWTON ST
Practice Address - Street 2:SUITE B
Practice Address - City:NORTH BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08902-2286
Practice Address - Country:US
Practice Address - Phone:888-897-6465
Practice Address - Fax:877-438-8976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-15
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ0397318251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0397318Medicaid