Provider Demographics
NPI:1295801207
Name:YOUNG, BRANDY DIANE (MCD,CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:BRANDY
Middle Name:DIANE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:MCD,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 YOUNG ST
Mailing Address - Street 2:
Mailing Address - City:TUCKERMAN
Mailing Address - State:AR
Mailing Address - Zip Code:72473-9327
Mailing Address - Country:US
Mailing Address - Phone:870-349-3037
Mailing Address - Fax:870-349-2104
Practice Address - Street 1:221 LINDLEY LANE
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:AR
Practice Address - Zip Code:72112
Practice Address - Country:US
Practice Address - Phone:870-523-2124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP1748235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARSP1748OtherSTATE LICENSE NUMBER
AR12029538OtherASHA PROVIDER NUMBER