Provider Demographics
NPI:1619050143
Name:SALLY S. YOUNG PHD, PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:SALLY S. YOUNG PHD, PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST - DOCTORATE
Authorized Official - Prefix:DR
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:SERRELL
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:802-862-2773
Mailing Address - Street 1:PO BOX 626
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05402-0626
Mailing Address - Country:US
Mailing Address - Phone:802-862-2773
Mailing Address - Fax:802-862-6496
Practice Address - Street 1:86 LAKE ST
Practice Address - Street 2:OFFICE 307
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-5297
Practice Address - Country:US
Practice Address - Phone:802-862-2773
Practice Address - Fax:802-862-6496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT480000178103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0008363OtherPTAN
VTVT6583Medicaid
VT0008363OtherPTAN