1548204076 NPI number — DR. MARTHA DRAKE YOUNG PH.D.

Table of content: DR. MARTHA DRAKE YOUNG PH.D. (NPI 1548204076)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548204076 NPI number — DR. MARTHA DRAKE YOUNG PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
YOUNG
Provider First Name:
MARTHA
Provider Middle Name:
DRAKE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
YOUNG
Provider Other First Name:
CHRIS
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PH.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1548204076
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 773805
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STEAMBOAT SPRINGS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80477-3805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-879-7637
Provider Business Mailing Address Fax Number:
970-871-6811

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
810 LINCOLN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STEAMBOAT SPRINGS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80487-4972
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-879-7637
Provider Business Practice Location Address Fax Number:
970-871-6811
Provider Enumeration Date:
06/15/2006

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: 103TC0700X , with the licence number:  840 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 016719 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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