Provider Demographics
NPI:1295886372
Name:SERVICE ORGANIZATION FOR YOUTH, INC.
Entity type:Organization
Organization Name:SERVICE ORGANIZATION FOR YOUTH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:FERMAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:ULIBARRI
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:575-445-8568
Mailing Address - Street 1:PO BOX 1165
Mailing Address - Street 2:
Mailing Address - City:RATON
Mailing Address - State:NM
Mailing Address - Zip Code:87740-1165
Mailing Address - Country:US
Mailing Address - Phone:575-445-8568
Mailing Address - Fax:505-445-0540
Practice Address - Street 1:101 LETTON DR
Practice Address - Street 2:
Practice Address - City:RATON
Practice Address - State:NM
Practice Address - Zip Code:87740-4366
Practice Address - Country:US
Practice Address - Phone:575-445-8568
Practice Address - Fax:575-445-0540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2472101YM0800X
NM3834101YA0400X
NM0108891101YM0800X
NMX-060961041C0700X
NM0108381101YM0800X
NMI-049321041C0700X
NMM-070451041C0700X
NMX-065791041C0700X
NMM-068321041C0700X
NMM-41771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM71525564Medicaid