=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285313635
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | YOUNG PATH COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2023
-----------------------------------------------------
Last Update Date | 07/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1209 WILSON AVE
-----------------------------------------------------
City | CHICAGO HEIGHTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60411-2438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-494-0350
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1209 WILSON AVE
-----------------------------------------------------
City | CHICAGO HEIGHTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60411-2438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-494-0350
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COUNSELOR
-----------------------------------------------------
Name | RAENETTE YOUNG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 773-494-0350
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------