Provider Demographics
NPI:1831323195
Name:STAR ACADEMY FOR YOUTH
Entity Type:Organization
Organization Name:STAR ACADEMY FOR YOUTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:BATHKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-773-3123
Mailing Address - Street 1:12279 BRADY DR
Mailing Address - Street 2:
Mailing Address - City:CUSTER
Mailing Address - State:SD
Mailing Address - Zip Code:57730-9160
Mailing Address - Country:US
Mailing Address - Phone:605-673-2521
Mailing Address - Fax:605-673-4654
Practice Address - Street 1:12279 BRADY DR
Practice Address - Street 2:
Practice Address - City:CUSTER
Practice Address - State:SD
Practice Address - Zip Code:57730-9160
Practice Address - Country:US
Practice Address - Phone:605-673-2521
Practice Address - Fax:605-673-4654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-14
Last Update Date:2009-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD5000360101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty