Healthcare Provider Details

I. General information

NPI: 1841609369
Provider Name (Legal Business Name): CRYSTAL YOUNG PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2014
Last Update Date: 08/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 E BELTLINE AVE SE SUITE 340
GRAND RAPIDS MI
49506-4301
US

IV. Provider business mailing address

1550 E BELTLINE AVE SE SUITE 340
GRAND RAPIDS MI
49506-4301
US

V. Phone/Fax

Practice location:
  • Phone: 616-862-5603
  • Fax:
Mailing address:
  • Phone: 616-862-5603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number6301015368
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number6301015368
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: