Basic Information
| Provider Information | |||||||||
| NPI: | 1902358930 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KENNETH YOUNG CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 ROHLWING RD | ||||||||
| Address2: | |||||||||
| City: | ELK GROVE VILLAGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600073217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475248800 | ||||||||
| FaxNumber: | 8475248824 | ||||||||
| Practice Location | |||||||||
| Address1: | 2418 E HINTZ RD | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600042268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475248800 | ||||||||
| FaxNumber: | 8475248824 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2016 | ||||||||
| LastUpdateDate: | 12/01/2016 | ||||||||
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| AuthorizedOfficialLastName: | COWEN | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICIER | ||||||||
| AuthorizedOfficialTelephone: | 8475248800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 000004086 | 05 | IL | MEDICAID |