1619050143 NPI number — SALLY S. YOUNG PHD, PROFESSIONAL CORPORATION

Table of content: (NPI 1619050143)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619050143 NPI number — SALLY S. YOUNG PHD, PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SALLY S. YOUNG PHD, PROFESSIONAL CORPORATION
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:
1619050143
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 626
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURLINGTON
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05402-0626
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-862-2773
Provider Business Mailing Address Fax Number:
802-862-6496

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
86 LAKE ST
Provider Second Line Business Practice Location Address:
OFFICE 307
Provider Business Practice Location Address City Name:
BURLINGTON
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05401-5297
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-862-2773
Provider Business Practice Location Address Fax Number:
802-862-6496
Provider Enumeration Date:
10/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
YOUNG
Authorized Official First Name:
SALLY
Authorized Official Middle Name:
SERRELL
Authorized Official Title or Position:
LICENSED PSYCHOLOGIST - DOCTORATE
Authorized Official Telephone Number:
802-862-2773

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  480000178 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0008363 . This is a "PTAN" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: VT6583 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".




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