Provider Demographics
NPI:1972364180
Name:YOUNG, NATHAN DALE (PRSS, CMII)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:DALE
Last Name:YOUNG
Suffix:
Gender:M
Credentials:PRSS, CMII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10701 NW 33RD ST
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-3459
Mailing Address - Country:US
Mailing Address - Phone:405-605-4005
Mailing Address - Fax:
Practice Address - Street 1:805 E ROBINSON ST
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-6610
Practice Address - Country:US
Practice Address - Phone:910-797-3602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-16
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YA0400X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)