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NPI Code Detail

MEDICARE: SHANE G. YOUNG MA, NCC, LPC

MEDICARE: SHANE G. YOUNG MA, NCC, LPC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YP2500XProfessional Counselor178015348IL

General Provider Information

NPI Number : 1194337147
Entity Type Code : Individual
Provider Name (Legal Business Name) : SHANE G. YOUNG MA, NCC, LPC
Provider Business Mailing Address
First Line : PO BOX 335
Second Line :
City : GLASFORD
State : IL
Zip : 61533-0335
Country : US
Telephone Number : 309-202-4417
Fax Number :
Provider Business Practice Location Address
First Line : 3020 W WILLOW KNOLLS DR
Second Line :
City : PEORIA
State : IL
Zip : 61614-8127
Country : US
Telephone Number : 309-681-5850
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/20/2020
Last Update Date : 08/20/2020

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