Provider Demographics
NPI:1558584300
Name:YOUNG-VERKUILEN, BETH (MS)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:YOUNG-VERKUILEN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W7175 FIRELANE 2
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-9401
Mailing Address - Country:US
Mailing Address - Phone:920-740-1065
Mailing Address - Fax:
Practice Address - Street 1:412 E LONGVIEW DR STE C
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-2168
Practice Address - Country:US
Practice Address - Phone:920-882-9877
Practice Address - Fax:920-882-9880
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI149-123106H00000X
WI149106H00000X
WI39041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39-1917728OtherTAXPAYOR ID