Basic Information
| Provider Information | |||||||||
| NPI: | 1306822127 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SPECIALIZED ALTERNATIVES FOR FAMILIES AND YOUTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10100 ELIDA RD | ||||||||
| Address2: | |||||||||
| City: | DELPHOS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458339056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196958010 | ||||||||
| FaxNumber: | 4196950565 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 DUTCH SQUARE BLVD | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292107317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037917328 | ||||||||
| FaxNumber: | 8037914198 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SCHULTE | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | JR ACCOUNTANT | ||||||||
| AuthorizedOfficialTelephone: | 4196958010 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | SR-0009100001-CPA | SC | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | SR0009100001CPA | 01 | SC | LISCENSE NUMBER | OTHER | 948MXH | 05 | SC | MEDICAID |