Provider Demographics
NPI:1366298978
Name:YOUNG, OLIVIA LYN
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:LYN
Last Name:YOUNG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:OLIVIA
Other - Middle Name:
Other - Last Name:O'CONNOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8113 LIMA RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46818-2162
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8113 LIMA RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46818-2162
Practice Address - Country:US
Practice Address - Phone:260-229-0345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-24
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty