Healthcare Provider Details

I. General information

NPI: 1346504891
Provider Name (Legal Business Name): STEPHENIE L YOUNG OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2012
Last Update Date: 11/17/2020
Certification Date: 11/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3123 N BROADWAY ST STE A
CHICAGO IL
60657-4522
US

IV. Provider business mailing address

942 N HOYNE AVE APT 2
CHICAGO IL
60622-4903
US

V. Phone/Fax

Practice location:
  • Phone: 773-880-5400
  • Fax: 773-880-5406
Mailing address:
  • Phone: 517-230-5871
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number046010569
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046010569
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: