Provider Demographics
NPI:1093348252
Name:YOUNG, MACY
Entity Type:Individual
Prefix:
First Name:MACY
Middle Name:
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:PO BOX 937
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:GA
Mailing Address - Zip Code:30445-0937
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:118 AZALEA RD STE 11
Practice Address - Street 2:
Practice Address - City:BAXLEY
Practice Address - State:GA
Practice Address - Zip Code:31513-9197
Practice Address - Country:US
Practice Address - Phone:912-705-2855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-17
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP009988235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist