Provider Demographics
NPI:1912179250
Name:YOUNG, MICHELLE LEIGH (MA)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LEIGH
Last Name:YOUNG
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MISS
Other - First Name:MICHELLE
Other - Middle Name:LEIGH
Other - Last Name:HARDING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS
Mailing Address - Street 1:701 W LAMM RD
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-9630
Mailing Address - Country:US
Mailing Address - Phone:815-233-6162
Mailing Address - Fax:815-233-6167
Practice Address - Street 1:701 W LAMM RD
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-9630
Practice Address - Country:US
Practice Address - Phone:815-233-6162
Practice Address - Fax:815-233-6167
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-27
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities