Basic Information
| Provider Information | |||||||||
| NPI: | 1215395751 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | CAEDY | ||||||||
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| Credential: | M.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1411 SW MORRISON ST | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972051945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033522400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1411 SW MORRISON ST | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972051945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033522400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2016 | ||||||||
| LastUpdateDate: | 01/28/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 500694103 | 05 | OR | MEDICAID |