Healthcare Provider Details

I. General information

NPI: 1083578827
Provider Name (Legal Business Name): SHAWNDA NICOLE YOUNG MS, LAC, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 E BEVERLY AVE STE B
KINGMAN AZ
86409-3564
US

IV. Provider business mailing address

812 TOPEKA ST
KINGMAN AZ
86401-6040
US

V. Phone/Fax

Practice location:
  • Phone: 928-753-9383
  • Fax:
Mailing address:
  • Phone: 949-391-8333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLAC-23345
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: