Provider Demographics
NPI:1871668871
Name:YOUTH DEVELOPMENT INSTITUTE
Entity Type:Organization
Organization Name:YOUTH DEVELOPMENT INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TRISH
Authorized Official - Middle Name:
Authorized Official - Last Name:COCOROS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-256-5311
Mailing Address - Street 1:1830 E ROOSEVELT ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-3641
Mailing Address - Country:US
Mailing Address - Phone:602-256-5300
Mailing Address - Fax:
Practice Address - Street 1:1050 N 19TH ST
Practice Address - Street 2:BLDG. A
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-3679
Practice Address - Country:US
Practice Address - Phone:602-256-5300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-311320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ877748OtherAHCCCS PROVIDER ID #