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General NPI Number Information
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NPI Number | 1689117368
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Entity Type | Individual
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Provider Name | CLORISSA YOUNG MA, LCPC
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Gender | Female
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Dates
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Enumeration Date | 11/29/2016
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Last Update Date | 07/19/2022
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Provider Practice Location Address
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Address Line | 92 CIRCLE DR W
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City | MONTGOMERY
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State | IL
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Zip | 60538-2502
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Country | US
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Telephone | 815-531-4561
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Fax |
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Provider Business Mailing Address
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Address Line | 92 CIRCLE DR W
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City | MONTGOMERY
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State | IL
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Zip | 60538-2502
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Country | US
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Telephone | 815-531-4561
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 180.012944
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 178.010903
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License Number State | IL
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