Provider Demographics
NPI:1124378526
Name:YOUNGREN, MELISSA (RN, BCBA)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:YOUNGREN
Suffix:
Gender:F
Credentials:RN, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12540 BROADWELL RD STE 2201
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:GA
Mailing Address - Zip Code:30004-6406
Mailing Address - Country:US
Mailing Address - Phone:404-400-5004
Mailing Address - Fax:
Practice Address - Street 1:12540 BROADWELL RD STE 2201
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:GA
Practice Address - Zip Code:30004-6406
Practice Address - Country:US
Practice Address - Phone:404-400-5004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-12
Last Update Date:2025-01-19
Deactivation Date:2024-12-05
Deactivation Code:
Reactivation Date:2025-01-10
Provider Licenses
StateLicense IDTaxonomies
12477487103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst