Healthcare Provider Details

I. General information

NPI: 1619697653
Provider Name (Legal Business Name): AZ YOUNG CHILD COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2022
Last Update Date: 08/30/2022
Certification Date: 08/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18001 N 79TH AVE STE C50
GLENDALE AZ
85308-8394
US

IV. Provider business mailing address

18001 N 79TH AVE STE C50
GLENDALE AZ
85308-8394
US

V. Phone/Fax

Practice location:
  • Phone: 480-269-1562
  • Fax: 623-328-9539
Mailing address:
  • Phone: 480-269-1562
  • Fax: 623-328-9539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: SARA RABAGO YOUNG
Title or Position: OWNER, THERAPIST
Credential: LCSW
Phone: 480-269-1562