Provider Demographics
NPI:1376896183
Name:YOUNG, DERANDORIA ANN (MSW)
Entity Type:Individual
Prefix:MRS
First Name:DERANDORIA
Middle Name:ANN
Last Name:YOUNG
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 FIRST STREET
Mailing Address - Street 2:BLDG 17
Mailing Address - City:HOLLOMAN AFB
Mailing Address - State:NM
Mailing Address - Zip Code:88330
Mailing Address - Country:US
Mailing Address - Phone:575-572-7061
Mailing Address - Fax:
Practice Address - Street 1:280 1ST ST
Practice Address - Street 2:BLDG 17
Practice Address - City:HOLLOMAN AFB
Practice Address - State:NM
Practice Address - Zip Code:88330-8273
Practice Address - Country:US
Practice Address - Phone:575-572-7061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-17
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPCSW-5071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical