Provider Demographics
NPI:1467666313
Name:YOUNG, SALLY SERRELL (PHD)
Entity Type:Individual
Prefix:DR
First Name:SALLY
Middle Name:SERRELL
Last Name:YOUNG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 N WILLIAMS ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-3304
Mailing Address - Country:US
Mailing Address - Phone:802-862-2773
Mailing Address - Fax:802-862-6496
Practice Address - Street 1:86 LAKE ST
Practice Address - Street 2:OFFICE 307
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-5297
Practice Address - Country:US
Practice Address - Phone:802-862-2773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT480000178103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTVT6583Medicaid
VTVT6583Medicare ID - Type UnspecifiedCLINICAL PSYCHOLOGIST