Basic Information
| Provider Information | |||||||||
| NPI: | 1194935940 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW, LADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 GREENHILL TER | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065151513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032883344 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 352 STATE ST | ||||||||
| Address2: | |||||||||
| City: | NORTH HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064733108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037814600 | ||||||||
| FaxNumber: | 2037814624 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2007 | ||||||||
| LastUpdateDate: | 01/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 000542 | CT | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | 005227 | CT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 300000542CT01 | 01 | CT | ANTHEM BCBS | OTHER | 022672 | 01 | CT | VMC AFFILIATE | OTHER | 500000315 | 05 | CT | MEDICAID | 140005227CT01 | 01 | CT | ANTHEM BCBS | OTHER | 303733 | 01 | CT | MHN | OTHER | 004082286 | 05 | CT | MEDICAID | 008022626 | 05 | CT | MEDICAID | 476270000 | 01 | CT | MAGELLAN | OTHER | 513954 | 01 | CT | VALUE OPTIONS | OTHER | 7944589 | 01 | CT | AETNA | OTHER | 004235083 | 05 | CT | MEDICAID |