Healthcare Provider Details

I. General information

NPI: 1154448538
Provider Name (Legal Business Name): REGINA SHERYL YOUNG CAC-M, SPEX, FAODP,
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 05/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9605 GRAND RIVER AVE
DETROIT MI
48204-2139
US

IV. Provider business mailing address

12305 DEXTER AVE
DETROIT MI
48206-1015
US

V. Phone/Fax

Practice location:
  • Phone: 313-834-5930
  • Fax: 313-834-4541
Mailing address:
  • Phone: 313-397-1306
  • Fax: 313-397-6010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: