Provider Demographics
NPI:1023572716
Name:YOUNG, COURTNEY CHANEL
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:CHANEL
Last Name:YOUNG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5515 PEMBROOK PL
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-3953
Mailing Address - Country:US
Mailing Address - Phone:517-763-5674
Mailing Address - Fax:
Practice Address - Street 1:5515 PEMBROOK PL
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-3953
Practice Address - Country:US
Practice Address - Phone:517-763-5674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-26
Last Update Date:2019-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer