Basic Information
| Provider Information | |||||||||
| NPI: | 1790339653 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | ALLEN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22 KENDIG LN | ||||||||
| Address2: | |||||||||
| City: | MARTINSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 254047773 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2404691383 | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 PEGASUS CT STE 500 | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 226024596 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403134196 | ||||||||
| FaxNumber: | 5406867906 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2019 | ||||||||
| LastUpdateDate: | 07/30/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.