Provider Demographics
NPI:1528604360
Name:YOUNG, MARY BETH (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:YOUNG
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1692 ELM PL
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33755-1317
Mailing Address - Country:US
Mailing Address - Phone:310-903-2141
Mailing Address - Fax:
Practice Address - Street 1:1692 ELM PL
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33755-1317
Practice Address - Country:US
Practice Address - Phone:310-903-2141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-26
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL17084235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty