Provider Demographics
NPI:1528377066
Name:YOUNG, LISA (BA/BHCM)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:YOUNG
Suffix:
Gender:F
Credentials:BA/BHCM
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 81
Mailing Address - Street 2:12880 NS 358
Mailing Address - City:BOWLEGS
Mailing Address - State:OK
Mailing Address - Zip Code:74830-0081
Mailing Address - Country:US
Mailing Address - Phone:405-380-5986
Mailing Address - Fax:
Practice Address - Street 1:12880 NS 358 RD
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:OK
Practice Address - Zip Code:74868
Practice Address - Country:US
Practice Address - Phone:405-380-5986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-01
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK20996171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator