Healthcare Provider Details

I. General information

NPI: 1164555090
Provider Name (Legal Business Name): KATIE J YOUNG MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 W CHESTNUT ST
BLOOMINGTON IL
61701-2814
US

IV. Provider business mailing address

802 N SHERIDAN RD A-3
PEORIA IL
61606-1996
US

V. Phone/Fax

Practice location:
  • Phone: 309-827-6026
  • Fax:
Mailing address:
  • Phone: 309-645-2257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: