1457441735 NPI number — SHANNON L. YOUNG LMFT

Table of content: SHANNON L. YOUNG LMFT (NPI 1457441735)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457441735 NPI number — SHANNON L. YOUNG LMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
YOUNG
Provider First Name:
SHANNON
Provider Middle Name:
L.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMFT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TREDENNICK
Provider Other First Name:
SHANNON
Provider Other Middle Name:
YOUNG
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMFT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1457441735
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2 POMPERAUG OFFICE PARK
Provider Second Line Business Mailing Address:
SUITE 206A
Provider Business Mailing Address City Name:
SOUTHBURY
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06488-2288
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-417-1908
Provider Business Mailing Address Fax Number:
203-791-9094

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2 POMPERAUG OFFICE PARK
Provider Second Line Business Practice Location Address:
SUITE 206A
Provider Business Practice Location Address City Name:
SOUTHBURY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06488-2288
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-417-1908
Provider Business Practice Location Address Fax Number:
203-791-9094
Provider Enumeration Date:
10/15/2006

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: 106H00000X , with the licence number:  000748 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 004187614 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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