Provider Demographics
NPI:1114002631
Name:YOUNG, MARK R (MSSW, LMSW, LCSW)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:R
Last Name:YOUNG
Suffix:
Gender:M
Credentials:MSSW, LMSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1012
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-8012
Mailing Address - Country:US
Mailing Address - Phone:906-776-4357
Mailing Address - Fax:
Practice Address - Street 1:427 S. STEPHENSON AVE., 2ND FLOOR
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801
Practice Address - Country:US
Practice Address - Phone:906-776-4357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2010-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010594571041C0700X
WI466-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI800891684OtherBLUE CROSS/BLUE SHIELD
MI0M65090Medicare ID - Type Unspecified