Basic Information
Provider Information
NPI: 1073925772
EntityType: 2
ReplacementNPI:  
OrganizationName: KENNETH YOUNG CENTER
LastName:  
FirstName:  
MiddleName:  
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Credential:  
OtherOrganizationName:  
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Mailing Information
Address1: 335 SCHREIBER AVE
Address2:  
City: ROSELLE
State: IL
PostalCode: 601721064
CountryCode: US
TelephoneNumber: 2242007378
FaxNumber:  
Practice Location
Address1: 1001 ROHLWING RD
Address2:  
City: ELK GROVE VILLAGE
State: IL
PostalCode: 600073217
CountryCode: US
TelephoneNumber: 8475248800
FaxNumber:  
Other Information
ProviderEnumerationDate: 05/29/2014
LastUpdateDate: 05/29/2014
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: ROMERO
AuthorizedOfficialFirstName: CATHY-ANN
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: HUMAN RESOURCE MANAGER
AuthorizedOfficialTelephone: 8475248800
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
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NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
251S00000X178.010050ILY AgenciesCommunity/Behavioral Health 

No ID Information.


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