Healthcare Provider Details

I. General information

NPI: 1467519777
Provider Name (Legal Business Name): JOE MICHAEL YOUNG SR. MA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 08/06/2020
Certification Date: 08/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1932 S GARLAND AVE
FAYETTEVILLE AR
72701-6841
US

IV. Provider business mailing address

PO BOX 9717
FAYETTEVILLE AR
72703-0031
US

V. Phone/Fax

Practice location:
  • Phone: 479-521-9902
  • Fax: 479-521-9902
Mailing address:
  • Phone: 479-521-9902
  • Fax: 479-521-9902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP9508020
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberM9802013
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: