=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174018360
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | YOLANDA LYNN QUEEN CDCA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2018
-----------------------------------------------------
Last Update Date | 06/29/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 LADY AVE
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45640-1018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-418-1487
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 394 RALPH ST
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45640-2037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-418-1487
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 080735
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------