Provider Demographics
NPI:1669139572
Name:FOUNDATION OF LOVE FOR YOUTH, LLC (FLY HOUSE)
Entity type:Organization
Organization Name:FOUNDATION OF LOVE FOR YOUTH, LLC (FLY HOUSE)
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:TYRA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW, CDCA, CPLC
Authorized Official - Phone:614-598-9891
Mailing Address - Street 1:PO BOX 992
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-0992
Mailing Address - Country:US
Mailing Address - Phone:614-429-3843
Mailing Address - Fax:614-675-7537
Practice Address - Street 1:850 OAK ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-1113
Practice Address - Country:US
Practice Address - Phone:614-429-3843
Practice Address - Fax:614-675-7537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-27
Last Update Date:2021-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No174200000XOther Service ProvidersMeals
No177F00000XOther Service ProvidersLodging
No251J00000XAgenciesNursing Care
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1881064004Medicaid