Provider Demographics
NPI:1275662645
Name:YOUNG, MARK (LPC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:YOUNG
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:713 COUNTY ROAD 2110
Mailing Address - Street 2:
Mailing Address - City:DAINGERFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:75638-4409
Mailing Address - Country:US
Mailing Address - Phone:903-918-5073
Mailing Address - Fax:903-285-6898
Practice Address - Street 1:650 CR 4650
Practice Address - Street 2:
Practice Address - City:MT. PLEASANT
Practice Address - State:TX
Practice Address - Zip Code:75455
Practice Address - Country:US
Practice Address - Phone:903-918-5073
Practice Address - Fax:903-645-2532
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-03
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19201101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1718785-01Medicaid
TX289291OtherAMERIGROUP
TX7089LCOtherBLUE CROSS BLUE SHIELD