1699358051 NPI number — GARDEN OF PRAYER YOUTH CENTER

Table of content: DR. KARYN LYNN AHO PH.D. (NPI 1295815009)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699358051 NPI number — GARDEN OF PRAYER YOUTH CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GARDEN OF PRAYER YOUTH CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699358051
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/04/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
657 E COURT ST STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KANKAKEE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60901-4071
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-933-2493
Provider Business Mailing Address Fax Number:
815-933-2494

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 SOUTH DIVISION
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AROMA PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60910-6009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-933-2493
Provider Business Practice Location Address Fax Number:
815-933-2494
Provider Enumeration Date:
05/04/2021

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HARRIS
Authorized Official First Name:
MIKKAL
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINICAL DIVISION DIRECTOR
Authorized Official Telephone Number:
815-933-2493

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)