Basic Information
| Provider Information | |||||||||
| NPI: | 1417036864 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | SOMERVILLE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021452935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172847000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 41 MALL RD | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018050001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817448610 | ||||||||
| FaxNumber: | 7817445235 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2006 | ||||||||
| LastUpdateDate: | 07/27/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 114162 | MA | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.