1083153142 NPI number — CONNIE J YOUNG-GIBRALTARIK MED, MA, LPC

Table of content: CONNIE J YOUNG-GIBRALTARIK MED, MA, LPC (NPI 1083153142)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083153142 NPI number — CONNIE J YOUNG-GIBRALTARIK MED, MA, LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
YOUNG-GIBRALTARIK
Provider First Name:
CONNIE
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MED, MA, LPC
Provider Gender Code:
F

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:
1083153142
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/23/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
950 EAGLES LANDING PKWY
Provider Second Line Business Mailing Address:
SUITE 665
Provider Business Mailing Address City Name:
STOCKBRIDGE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30281-7343
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-914-7540
Provider Business Mailing Address Fax Number:
770-629-2139

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
950 EAGLES LANDING PKWY
Provider Second Line Business Practice Location Address:
SUITE 665
Provider Business Practice Location Address City Name:
STOCKBRIDGE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30281-7343
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-914-7540
Provider Business Practice Location Address Fax Number:
770-629-2139
Provider Enumeration Date:
02/21/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  LPC009420 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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