Basic Information
| Provider Information | |||||||||
| NPI: | 1528533064 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | CARMELITA | ||||||||
| MiddleName: | |||||||||
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| OtherOrganizationType: | |||||||||
| OtherLastName: | HOSKINS | ||||||||
| OtherFirstName: | CARMELITA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 360 E BELTLINE AVE NE STE 100 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495061214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6168053660 | ||||||||
| FaxNumber: | 6168053631 | ||||||||
| Practice Location | |||||||||
| Address1: | 1403 60TH ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495087065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6168053660 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2018 | ||||||||
| LastUpdateDate: | 03/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6401019171 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.