Provider Demographics
NPI:1396095501
Name:YOUNG, RENEE PAULINE
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:PAULINE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2412 DONNER AVE
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74604-2811
Mailing Address - Country:US
Mailing Address - Phone:580-304-2069
Mailing Address - Fax:
Practice Address - Street 1:222 E GRAND AVE STE 300
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-4316
Practice Address - Country:US
Practice Address - Phone:405-939-0559
Practice Address - Fax:580-916-9538
Is Sole Proprietor?:No
Enumeration Date:2012-09-14
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OK1136101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator