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General NPI Number Information
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NPI Number | 1619050143
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Entity Type | Organization
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Legal Business Name | SALLY S. YOUNG PHD, PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 10/20/2006
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Last Update Date | 03/07/2011
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Provider Practice Location Address
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Address Line | 86 LAKE ST OFFICE 307
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City | BURLINGTON
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State | VT
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Zip | 05401-5297
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Country | US
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Telephone | 802-862-2773
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Fax | 802-862-6496
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Provider Business Mailing Address
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Address Line | PO BOX 626
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City | BURLINGTON
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State | VT
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Zip | 05402-0626
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Country | US
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Telephone | 802-862-2773
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Fax | 802-862-6496
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Authorized Official
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Title or Position | LICENSED PSYCHOLOGIST - DOCTORATE
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Name | DR. SALLY SERRELL YOUNG
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Credential | PHD
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Telephone | 802-862-2773
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 480000178
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License Number State | VT
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