Provider Demographics
NPI:1952071706
Name:YOUNGER-QUALLS, TINESHA DOMINIQUE (LPC, ACD)
Entity Type:Individual
Prefix:
First Name:TINESHA
Middle Name:DOMINIQUE
Last Name:YOUNGER-QUALLS
Suffix:
Gender:F
Credentials:LPC, ACD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9959 E PEAKVIEW AVE APT M201
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80111-6167
Mailing Address - Country:US
Mailing Address - Phone:720-917-4341
Mailing Address - Fax:
Practice Address - Street 1:9959 E PEAKVIEW AVE APT M201
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80111-6167
Practice Address - Country:US
Practice Address - Phone:720-917-4341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACD.0001815101YA0400X
COLPC.0016122101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)