Provider Demographics
NPI:1225549231
Name:YOUNG, JAMES FIDAL (PSY D, LPC)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:FIDAL
Last Name:YOUNG
Suffix:
Gender:M
Credentials:PSY D, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 NW 28TH WAY
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33311-8533
Mailing Address - Country:US
Mailing Address - Phone:312-576-8147
Mailing Address - Fax:
Practice Address - Street 1:105 NW 28TH WAY
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33311-8533
Practice Address - Country:US
Practice Address - Phone:312-576-8147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-17
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.007359101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional