Healthcare Provider Details

I. General information

NPI: 1295105880
Provider Name (Legal Business Name): ZETAH YOUNG LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2015
Last Update Date: 09/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4730 N SHERIDAN RD
CHICAGO IL
60640-5022
US

IV. Provider business mailing address

4730 N SHERIDAN RD
CHICAGO IL
60640-5022
US

V. Phone/Fax

Practice location:
  • Phone: 773-506-7474
  • Fax: 773-506-9420
Mailing address:
  • Phone: 773-506-7474
  • Fax: 773-506-9420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180009911
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: