Healthcare Provider Details

I. General information

NPI: 1447405915
Provider Name (Legal Business Name): MENTREL STANLEY YOUNG DSC.,C.N.S.,C.D.-N.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2008
Last Update Date: 01/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 HAWTHORNE ST
BRIDGEPORT CT
06610-1606
US

IV. Provider business mailing address

79 HAWTHORNE ST
BRIDGEPORT CT
06610-1606
US

V. Phone/Fax

Practice location:
  • Phone: 203-400-1990
  • Fax:
Mailing address:
  • Phone: 203-400-1990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number000870
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: