Provider Demographics
NPI:1154673325
Name:YOUNG, MELISSA (BCABA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:YOUNG
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2585 W LAKE DR
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32724-3282
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2585 W LAKE DR
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32724-3282
Practice Address - Country:US
Practice Address - Phone:407-617-4954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-11
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X, 252Y00000X, 252Y00000X
FL103K00000X, 252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111966400Medicaid
FL1154673335Medicaid
FL1154673325Medicaid