Provider Demographics
NPI:1487693891
Name:YOUNG, MYRNA BORBON (LPC)
Entity type:Individual
Prefix:
First Name:MYRNA
Middle Name:BORBON
Last Name:YOUNG
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 E POPLAR ST STE C&D
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-2532
Mailing Address - Country:US
Mailing Address - Phone:479-435-6047
Mailing Address - Fax:479-755-3595
Practice Address - Street 1:130 E POPLAR ST STE C&D
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703
Practice Address - Country:US
Practice Address - Phone:479-435-6047
Practice Address - Fax:479-755-3595
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA0507049101YM0800X
ARP0807060101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR207210719Medicaid