MEDICARE: MRS. QIANA RENEE' YOUNG LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	P1705292	AR
2	101YM0800X	Mental Health Counselor	A1405077	AR

General Provider Information

NPI Number	:	1578705026
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. QIANA RENEE' YOUNG LPC

Provider Business Mailing Address
First Line	:	864 MONTCLAIR ST
Second Line	:
City	:	BENTON
State	:	AR
Zip	:	72015-3889
Country	:	US
Telephone Number	:	501-442-0911
Fax Number	:

Provider Business Practice Location Address
First Line	:	17680 I 30 STE 1
Second Line	:
City	:	BENTON
State	:	AR
Zip	:	72019-2921
Country	:	US
Telephone Number	:	501-575-2344
Fax Number	:	501-242-7009

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/30/2009
Last Update Date	:	07/13/2021

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