Provider Demographics
NPI:1861034704
Name:YOUNG MIND THERAPY, LLC
Entity Type:Organization
Organization Name:YOUNG MIND THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:A
Authorized Official - Last Name:LANGDON
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:517-290-3774
Mailing Address - Street 1:1984 LIVE OAK TRL
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48895-9344
Mailing Address - Country:US
Mailing Address - Phone:517-290-3774
Mailing Address - Fax:
Practice Address - Street 1:1235 E GRAND RIVER RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSTON
Practice Address - State:MI
Practice Address - Zip Code:48895-8303
Practice Address - Country:US
Practice Address - Phone:517-588-6083
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-11
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1164070967OtherNPI 1