Healthcare Provider Details

I. General information

NPI: 1124753959
Provider Name (Legal Business Name): SHANI A YOUNG LIFE COACH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2022
Last Update Date: 01/30/2024
Certification Date: 01/30/2024
Deactivation Date: 01/18/2024
Reactivation Date: 01/23/2024

III. Provider practice location address

5104 N 20TH ST
MILWAUKEE WI
53209-5717
US

IV. Provider business mailing address

5104 N 20TH ST
MILWAUKEE WI
53209-5717
US

V. Phone/Fax

Practice location:
  • Phone: 414-630-1169
  • Fax:
Mailing address:
  • Phone: 414-630-1169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number20467-130
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: