Provider Demographics
NPI:1447405915
Name:YOUNG, MENTREL STANLEY (DSC,CNS,CD-N)
Entity Type:Individual
Prefix:DR
First Name:MENTREL
Middle Name:STANLEY
Last Name:YOUNG
Suffix:
Gender:M
Credentials:DSC,CNS,CD-N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 HAWTHORNE ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06610-1606
Mailing Address - Country:US
Mailing Address - Phone:203-400-1990
Mailing Address - Fax:
Practice Address - Street 1:79 HAWTHORNE ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06610-1606
Practice Address - Country:US
Practice Address - Phone:203-400-1990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-24
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000870133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist