Healthcare Provider Details

I. General information

NPI: 1689249583
Provider Name (Legal Business Name): MALLORI YOUNG MS TLLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2021
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 N CENTER ST
NORTHVILLE MI
48167-1277
US

IV. Provider business mailing address

925 LAPRAIRIE ST APT 120
FERNDALE MI
48220-2475
US

V. Phone/Fax

Practice location:
  • Phone: 313-656-4052
  • Fax:
Mailing address:
  • Phone: 734-756-6961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6362009306
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: