Provider Demographics
NPI:1386179802
Name:YOUNG, KENNETH (CDCA)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:YOUNG
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:341 STADIUM ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44906-2543
Mailing Address - Country:US
Mailing Address - Phone:567-560-7713
Mailing Address - Fax:
Practice Address - Street 1:169 MANSFIELD AVE
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:OH
Practice Address - Zip Code:44875-1832
Practice Address - Country:US
Practice Address - Phone:419-292-9211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-21
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.161465101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)