Healthcare Provider Details

I. General information

NPI: 1811022809
Provider Name (Legal Business Name): KELLY C YOUNG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 05/16/2025
Certification Date: 05/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 RESERVOIR AVE STE 203
CRANSTON RI
02920-6032
US

IV. Provider business mailing address

6535 BRIARWOOD PL
ZIONSVILLE IN
46077-8541
US

V. Phone/Fax

Practice location:
  • Phone: 401-259-0340
  • Fax: 401-213-8538
Mailing address:
  • Phone: 317-431-3828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPS02341
License Number StateRI
# 3
Primary TaxonomyY
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License NumberPS02341
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: