Provider Demographics
NPI:1891937116
Name:YOUNG, DELORES DIANNE (LISAC)
Entity Type:Individual
Prefix:
First Name:DELORES
Middle Name:DIANNE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1660 W VERDE DR
Mailing Address - Street 2:
Mailing Address - City:WICKENBURG
Mailing Address - State:AZ
Mailing Address - Zip Code:85390
Mailing Address - Country:US
Mailing Address - Phone:928-231-1032
Mailing Address - Fax:
Practice Address - Street 1:15270 W BROOKSIDE LN
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374
Practice Address - Country:US
Practice Address - Phone:928-231-1032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-01
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11359101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ101YA0400XOtherCOUNSELOR-ADDICTIONS