Provider Demographics
NPI:1124748546
Name:YOUTH SERVICE BUREAU OF ILLINIOS VALLEY
Entity type:Organization
Organization Name:YOUTH SERVICE BUREAU OF ILLINIOS VALLEY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL ADM ASST
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-433-3953
Mailing Address - Street 1:424 W MADISON ST
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:IL
Mailing Address - Zip Code:61350-2833
Mailing Address - Country:US
Mailing Address - Phone:815-433-3953
Mailing Address - Fax:815-433-3980
Practice Address - Street 1:4231 PROGRESS BLVD STE 1
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-1193
Practice Address - Country:US
Practice Address - Phone:815-433-3953
Practice Address - Fax:815-433-3980
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:YOUTH SERVICE BUREAU OF ILLINIOS VALLEY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-08-29
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral Health