Basic Information
| Provider Information | |||||||||
| NPI: | 1639201825 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | PATRICK | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12851 GRAND RIVER RD | ||||||||
| Address2: | |||||||||
| City: | BRIGHTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481168506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102271211 | ||||||||
| FaxNumber: | 8102205509 | ||||||||
| Practice Location | |||||||||
| Address1: | 12851 GRAND RIVER RD | ||||||||
| Address2: | |||||||||
| City: | BRIGHTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481168506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102271211 | ||||||||
| FaxNumber: | 8102205509 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2007 | ||||||||
| LastUpdateDate: | 05/12/2017 | ||||||||
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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 | 101Y00000X | 640100948 | MI | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.