Provider Demographics
NPI:1598865339
Name:YOUNG, MAE C (EDS)
Entity Type:Individual
Prefix:
First Name:MAE
Middle Name:C
Last Name:YOUNG
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 GOODMAN RD E
Mailing Address - Street 2:SUITE 102 BUILDING 3
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-5154
Mailing Address - Country:US
Mailing Address - Phone:662-349-2148
Mailing Address - Fax:662-349-6626
Practice Address - Street 1:230 GOODMAN RD E
Practice Address - Street 2:SUITE 102 BUILDING 3
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-5154
Practice Address - Country:US
Practice Address - Phone:662-349-2148
Practice Address - Fax:662-349-6626
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0633101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional