Healthcare Provider Details

I. General information

NPI: 1972364180
Provider Name (Legal Business Name): NATHAN DALE YOUNG PRSS, CMII
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2024
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 S MUSTANG RD
YUKON OK
73099-6767
US

IV. Provider business mailing address

10701 NW 33RD ST
YUKON OK
73099-3459
US

V. Phone/Fax

Practice location:
  • Phone: 405-283-3680
  • Fax:
Mailing address:
  • Phone: 405-283-3680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPCC13514
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: