Provider Demographics
NPI:1841425360
Name:YOUNG, MEDINA
Entity Type:Individual
Prefix:
First Name:MEDINA
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 1:900 RESERVOIR AVE
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02910-4453
Mailing Address - Country:US
Mailing Address - Phone:401-230-7841
Mailing Address - Fax:
Practice Address - Street 1:900 RESERVOIR AVE
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02910-4453
Practice Address - Country:US
Practice Address - Phone:401-230-7841
Practice Address - Fax:401-632-4880
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-28
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILCDP00211101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)