Healthcare Provider Details

I. General information

NPI: 1639330681
Provider Name (Legal Business Name): RACHAEL LEE YOUNG LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RACHAEL LEE DERGO LCSW

II. Dates (important events)

Enumeration Date: 06/23/2008
Last Update Date: 11/22/2023
Certification Date: 11/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6010 AMARILLO BLVD WEST
AMARILLO TX
79106
US

IV. Provider business mailing address

6804 NANCY ELLEN STREET
AMARILLO TX
79119
US

V. Phone/Fax

Practice location:
  • Phone: 806-355-9703
  • Fax: 217-373-2444
Mailing address:
  • Phone: 217-373-2430
  • Fax: 217-373-2444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.015129
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: