Provider Demographics
NPI:1144907841
Name:ADVANCED YOUTH COUNSELING LLC
Entity type:Organization
Organization Name:ADVANCED YOUTH COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:DESIREE
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:121-676-7997
Mailing Address - Street 1:3631 BEACON DR
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-6008
Mailing Address - Country:US
Mailing Address - Phone:216-767-9971
Mailing Address - Fax:
Practice Address - Street 1:3631 BEACON DR
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-6008
Practice Address - Country:US
Practice Address - Phone:216-767-9971
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-03
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty