Provider Demographics
NPI:1427755404
Name:YOUNG, NICKCOLE MELANIE (BI)
Entity type:Individual
Prefix:
First Name:NICKCOLE
Middle Name:MELANIE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:BI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5202 LUCKY AVE APT A2
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-2395
Mailing Address - Country:US
Mailing Address - Phone:208-380-2249
Mailing Address - Fax:
Practice Address - Street 1:5202 LUCKY AVE APT A2
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-2395
Practice Address - Country:US
Practice Address - Phone:208-380-2249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-10
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty