Provider Demographics
NPI:1679917363
Name:YOUNG, TEAVIS VALENCIA
Entity Type:Individual
Prefix:MS
First Name:TEAVIS
Middle Name:VALENCIA
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 1:500 N ACADEMY ST
Mailing Address - Street 2:
Mailing Address - City:KINGSTREE
Mailing Address - State:SC
Mailing Address - Zip Code:29556-3408
Mailing Address - Country:US
Mailing Address - Phone:843-355-5533
Mailing Address - Fax:
Practice Address - Street 1:500 N ACADEMY ST
Practice Address - Street 2:
Practice Address - City:KINGSTREE
Practice Address - State:SC
Practice Address - Zip Code:29556-3408
Practice Address - Country:US
Practice Address - Phone:843-355-5533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-24
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC$$$$$$$$$Medicaid