Basic Information
| Provider Information | |||||||||
| NPI: | 1205805454 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | CORINNE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSYD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | YOUNG HARDESTY | ||||||||
| OtherFirstName: | CORINNE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5101 E US HIGHWAY 36 | ||||||||
| Address2: | STE 100 | ||||||||
| City: | AVON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461236646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128910601 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6655 E US HIGHWAY 36 | ||||||||
| Address2: | |||||||||
| City: | AVON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8887141927 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2006 | ||||||||
| LastUpdateDate: | 03/17/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 20060006590 | MO | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 20042291A | IN | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 200930090 | 05 | IN | MEDICAID |