Provider Demographics
NPI:1336351469
Name:NATIONAL YOUTH ADVOCATE PROGRAM
Entity type:Organization
Organization Name:NATIONAL YOUTH ADVOCATE PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR, WV
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLENBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:MSWLGSW
Authorized Official - Phone:304-363-4237
Mailing Address - Street 1:1036 SPEEDWAY AVENUE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554
Mailing Address - Country:US
Mailing Address - Phone:304-363-4237
Mailing Address - Fax:304-366-5863
Practice Address - Street 1:1036 SPEEDWAY AVENUE
Practice Address - Street 2:SUITE 2
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554
Practice Address - Country:US
Practice Address - Phone:304-363-4237
Practice Address - Fax:304-366-5863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV97251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0023630001Medicaid