Basic Information
Provider Information
NPI: 1003003989
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: YOUNG
FirstName: MICHELLE
MiddleName: LOREEN
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 680 W NYE LN
Address2: SUITE 102
City: CARSON CITY
State: NV
PostalCode: 897031541
CountryCode: US
TelephoneNumber: 7758849911
FaxNumber: 7758849913
Practice Location
Address1: 680 W NYE LN
Address2: SUITE 102
City: CARSON CITY
State: NV
PostalCode: 897031541
CountryCode: US
TelephoneNumber: 7758849911
FaxNumber: 7758849913
Other Information
ProviderEnumerationDate: 09/25/2007
LastUpdateDate: 09/25/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
104100000X  Y Behavioral Health & Social Service ProvidersSocial Worker 

No ID Information.


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