Provider Demographics
NPI:1326090770
Name:YOUNG, PETER BERNHART (PHD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:BERNHART
Last Name:YOUNG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10820 KINGSTON PIKE
Mailing Address - Street 2:SUITE 21
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37934-3066
Mailing Address - Country:US
Mailing Address - Phone:865-671-6935
Mailing Address - Fax:865-675-0502
Practice Address - Street 1:10820 KINGSTON PIKE
Practice Address - Street 2:SUITE 21
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37934-3066
Practice Address - Country:US
Practice Address - Phone:865-671-6935
Practice Address - Fax:865-675-0502
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP-1466103G00000X, 103TC0700X
WV718103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3684340Medicaid
WV718OtherPSYCHOLOGY LICENSE #
TN2007179OtherBLUECROSSBLUESHIELD
TNP-1466OtherPSYCHOLOGY LICENSE #
TNP-1466OtherPSYCHOLOGY LICENSE #