Provider Demographics
NPI:1871177832
Name:YOUNG, LAURINE
Entity type:Individual
Prefix:MS
First Name:LAURINE
Middle Name:
Last Name:YOUNG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAURINE
Other - Middle Name:
Other - Last Name:YOUNGJACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3118 GALILEO LN
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-5463
Mailing Address - Country:US
Mailing Address - Phone:617-669-5965
Mailing Address - Fax:
Practice Address - Street 1:3118 GALILEO LN
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-5463
Practice Address - Country:US
Practice Address - Phone:617-669-5965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-06
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONLC.0108587101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty