Basic Information
| Provider Information | |||||||||
| NPI: | 1194399253 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | R | ||||||||
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| Mailing Information | |||||||||
| Address1: | MSC09-5030 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052725428 | ||||||||
| FaxNumber: | 5052724921 | ||||||||
| Practice Location | |||||||||
| Address1: | 10300 GOLF COURSE RD NW APT 1316 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871143927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052725428 | ||||||||
| FaxNumber: | 5052724921 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2021 | ||||||||
| LastUpdateDate: | 06/16/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 05/25/2021 | ||||||||
| NPIReactivationDate: | 06/16/2021 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC1900X | N | Behavioral Health & Social Service Providers | Psychologist | Counseling | 390200000X | NM | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.