Provider Demographics
NPI:1609345453
Name:YOUNG, ANTONIA MARIE
Entity Type:Individual
Prefix:
First Name:ANTONIA
Middle Name:MARIE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 EMERSON ST RM 311
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-3810
Mailing Address - Country:US
Mailing Address - Phone:612-730-3861
Mailing Address - Fax:
Practice Address - Street 1:630 EMERSON ST RM 311
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-3810
Practice Address - Country:US
Practice Address - Phone:612-730-3861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-21
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician