Provider Demographics
NPI:1699358051
Name:GARDEN OF PRAYER YOUTH CENTER
Entity Type:Organization
Organization Name:GARDEN OF PRAYER YOUTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIVISION DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MIKKAL
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LCPC
Authorized Official - Phone:815-933-2493
Mailing Address - Street 1:657 E COURT ST STE 200
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-4071
Mailing Address - Country:US
Mailing Address - Phone:815-933-2493
Mailing Address - Fax:815-933-2494
Practice Address - Street 1:101 SOUTH DIVISION
Practice Address - Street 2:
Practice Address - City:AROMA PARK
Practice Address - State:IL
Practice Address - Zip Code:60910-6009
Practice Address - Country:US
Practice Address - Phone:815-933-2493
Practice Address - Fax:815-933-2494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-04
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)