Healthcare Provider Details

I. General information

NPI: 1376896183
Provider Name (Legal Business Name): DERANDORIA ANN YOUNG MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2012
Last Update Date: 10/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 1ST ST BLDG 17
HOLLOMAN AFB NM
88330-8273
US

IV. Provider business mailing address

280 FIRST STREET BLDG 17
HOLLOMAN AFB NM
88330
US

V. Phone/Fax

Practice location:
  • Phone: 575-572-7061
  • Fax:
Mailing address:
  • Phone: 575-572-7061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberPCSW-507
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: