=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053862458
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | COLLEEN A. YOUNG M.A./ED.S., LPC, NCC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2016
-----------------------------------------------------
Last Update Date | 10/20/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 776 MOUNTAIN BLVD SUITE 106
-----------------------------------------------------
City | WATCHUNG
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07069-6269
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-385-8366
-----------------------------------------------------
Fax | 908-754-4882
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 37 CENTURY LN
-----------------------------------------------------
City | WATCHUNG
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07069-6007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-385-8366
-----------------------------------------------------
Fax | 908-754-4882
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 37PC00555600
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------