Provider Demographics
NPI:1760855266
Name:WOODWARD YOUTH CORPORATION
Entity Type:Organization
Organization Name:WOODWARD YOUTH CORPORATION
Other - Org Name:WOODWARD COMMUNITY BASED SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLENKAMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-237-4050
Mailing Address - Street 1:611 5TH AVE
Mailing Address - Street 2:GROUND LEVEL
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50309-1603
Mailing Address - Country:US
Mailing Address - Phone:515-274-9607
Mailing Address - Fax:515-274-9614
Practice Address - Street 1:611 5TH AVE
Practice Address - Street 2:GROUND LEVEL
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-1603
Practice Address - Country:US
Practice Address - Phone:515-274-9607
Practice Address - Fax:515-274-9614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA317887251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1140012Medicaid