Provider Demographics
NPI:1124753959
Name:YOUNG, SHANI A (LIFE COACH)
Entity type:Individual
Prefix:
First Name:SHANI
Middle Name:A
Last Name:YOUNG
Suffix:
Gender:F
Credentials:LIFE COACH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5104 N 20TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-5717
Mailing Address - Country:US
Mailing Address - Phone:414-630-1169
Mailing Address - Fax:
Practice Address - Street 1:5104 N 20TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-5717
Practice Address - Country:US
Practice Address - Phone:414-630-1169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-17
Last Update Date:2024-01-30
Deactivation Date:2024-01-18
Deactivation Code:
Reactivation Date:2024-01-23
Provider Licenses
StateLicense IDTaxonomies
101YP2500X, 171400000X
WI20467-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171400000XOther Service ProvidersHealth & Wellness Coach
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI101YA0400XOtherWI STATE DSPS
171400000XOtherEDUCATIONAL COURSE