Provider Demographics
NPI:1720495179
Name:YOUNGSTROM, CAROL SUE
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:SUE
Last Name:YOUNGSTROM
Suffix:
Gender:F
Credentials:
Other - Prefix:MR
Other - First Name:SCOTT
Other - Middle Name:ERIC
Other - Last Name:YOUNGSTROM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CPO
Mailing Address - Street 1:13440 SW 19TH PL
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34481-4006
Mailing Address - Country:US
Mailing Address - Phone:352-854-9826
Mailing Address - Fax:352-629-2359
Practice Address - Street 1:13440 SW 19TH PL
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34481-4006
Practice Address - Country:US
Practice Address - Phone:352-854-9826
Practice Address - Fax:352-629-2359
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-17
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLJB120516171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor