Provider Demographics
NPI:1477976165
Name:YOUNG, TONY RAY (PHD, MP)
Entity Type:Individual
Prefix:DR
First Name:TONY
Middle Name:RAY
Last Name:YOUNG
Suffix:
Gender:M
Credentials:PHD, MP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-6211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:622 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-6211
Practice Address - Country:US
Practice Address - Phone:318-398-0945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-30
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMP.000034103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)