Provider Demographics
NPI:1376196105
Name:YOUNG, TERRENCE
Entity Type:Individual
Prefix:
First Name:TERRENCE
Middle Name:
Last Name:YOUNG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 PADRE PKWY STE 101
Mailing Address - Street 2:
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928-2114
Mailing Address - Country:US
Mailing Address - Phone:707-553-1784
Mailing Address - Fax:
Practice Address - Street 1:2 PADRE PKWY STE 101
Practice Address - Street 2:
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928-2114
Practice Address - Country:US
Practice Address - Phone:707-553-1748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-21
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician