Basic Information
| Provider Information | |||||||||
| NPI: | 1245686039 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | DANA | ||||||||
| MiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1639 FORUM | ||||||||
| Address2: | SUITE #7 | ||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617128821 | ||||||||
| FaxNumber: | 5617128070 | ||||||||
| Practice Location | |||||||||
| Address1: | 1639 FORUM | ||||||||
| Address2: | SUITE #7 | ||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617128821 | ||||||||
| FaxNumber: | 5617128070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2016 | ||||||||
| LastUpdateDate: | 05/15/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 01/10/2019 | ||||||||
| NPIReactivationDate: | 05/15/2019 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.