Provider Demographics
NPI:1649834441
Name:YOUNG, STACEY R
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:R
Last Name:YOUNG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 E BROAD ST STE 103
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43203-2012
Mailing Address - Country:US
Mailing Address - Phone:614-340-5592
Mailing Address - Fax:614-448-3344
Practice Address - Street 1:2700 E MAIN ST STE 110
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43209-2536
Practice Address - Country:US
Practice Address - Phone:614-340-5922
Practice Address - Fax:614-448-3344
Is Sole Proprietor?:No
Enumeration Date:2019-04-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
No235500000XSpeech, Language and Hearing Service ProvidersSpecialist/Technologist