Provider Demographics
NPI:1689219669
Name:YOUNG, NEDRA
Entity Type:Individual
Prefix:
First Name:NEDRA
Middle Name:
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 1:3413 SHERLAWN DR
Mailing Address - Street 2:
Mailing Address - City:MOSS POINT
Mailing Address - State:MS
Mailing Address - Zip Code:39563-3836
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1916 LADNIER RD
Practice Address - Street 2:
Practice Address - City:GAUTIER
Practice Address - State:MS
Practice Address - Zip Code:39553-7306
Practice Address - Country:US
Practice Address - Phone:228-497-0690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-13
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018214Medicaid