Provider Demographics
NPI:1447949235
Name:YOUNG, SHAQUTTO MICHELLE
Entity type:Individual
Prefix:
First Name:SHAQUTTO
Middle Name:MICHELLE
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 1:205 LAKESHORE PT
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558-3843
Mailing Address - Country:US
Mailing Address - Phone:256-496-4757
Mailing Address - Fax:
Practice Address - Street 1:205 LAKESHORE PT
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-3843
Practice Address - Country:US
Practice Address - Phone:256-496-4757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-05
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW011123104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker