Basic Information
Provider Information | |||||||||
NPI: | 1265685085 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | YOUNG TALKERS, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4720 HWY 17 BYP S STE E | ||||||||
Address2: |   | ||||||||
City: | MYRTLE BEACH | ||||||||
State: | SC | ||||||||
PostalCode: | 295881622 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8434571053 | ||||||||
FaxNumber: | 8432939110 | ||||||||
Practice Location | |||||||||
Address1: | 4720 HWY 17 BYP S STE E | ||||||||
Address2: |   | ||||||||
City: | MYRTLE BEACH | ||||||||
State: | SC | ||||||||
PostalCode: | 295881622 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8434571053 | ||||||||
FaxNumber: | 8432939110 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/23/2008 | ||||||||
LastUpdateDate: | 10/23/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | YOUNG | ||||||||
AuthorizedOfficialFirstName: | NICOLE | ||||||||
AuthorizedOfficialMiddleName: | MICHELLE | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR/SPEECH THERAPIST | ||||||||
AuthorizedOfficialTelephone: | 8434571053 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.A., CCC-SLP | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 3868 | SC | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
ID Information
ID | Type | State | Issuer | Description | SA0704 | 05 | SC |   | MEDICAID |