Provider Demographics
NPI:1528687092
Name:PA SPROUT MC 1 LLC
Entity type:Organization
Organization Name:PA SPROUT MC 1 LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YURY
Authorized Official - Middle Name:
Authorized Official - Last Name:YAKUBCHYK
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:267-440-7754
Mailing Address - Street 1:196 W ASHLAND ST
Mailing Address - Street 2:
Mailing Address - City:DOYLESTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18901-4040
Mailing Address - Country:US
Mailing Address - Phone:833-991-2368
Mailing Address - Fax:929-384-7193
Practice Address - Street 1:196 W ASHLAND ST
Practice Address - Street 2:
Practice Address - City:DOYLESTOWN
Practice Address - State:PA
Practice Address - Zip Code:18901-4040
Practice Address - Country:US
Practice Address - Phone:833-991-2368
Practice Address - Fax:929-384-7193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-14
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty