=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861034704
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | YOUNG MIND THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2019
-----------------------------------------------------
Last Update Date | 10/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1235 E GRAND RIVER RD
-----------------------------------------------------
City | WILLIAMSTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48895-8303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-588-6083
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1984 LIVE OAK TRL
-----------------------------------------------------
City | WILLIAMSTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48895-9344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-290-3774
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL SOCIAL WORKER
-----------------------------------------------------
Name | NICOLE A LANGDON
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 517-290-3774
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------