Healthcare Provider Details

I. General information

NPI: 1104736719
Provider Name (Legal Business Name): AUTUMN YOUNG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5855 EXECUTIVE CENTER DR STE 105
CHARLOTTE NC
28212-8880
US

IV. Provider business mailing address

6220 THERMAL RD
CHARLOTTE NC
28211-5630
US

V. Phone/Fax

Practice location:
  • Phone: 704-366-8712
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: